Chronic Gastrointestinal Complaints Research Articles

Gastrointestinal and nutritional issues in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type.

Gastrointestinal involvement is a well known complication of Ehlers-Danlos syndromes (EDSs), mainly in form of abdominal emergencies due to intestinal/abdominal vessels rupture in vascular EDS. In the last decade, a growing number of works investigated the relationship between a wide spectrum of chronic gastrointestinal complaints and various EDS forms, among which the hypermobility type (a.k.a. joint hypermobility syndrome; JHS/EDS-HT) was the most studied. The emerging findings depict a major role for gastrointestinal involvement in the health status and, consequently, management of JHS/EDS-HT patients. Nevertheless, fragmentation of knowledge limits its impact on practice within the boundaries of highly specialized clinics. In this paper, literature review on gastrointestinal manifestations in JHS/EDS-HT was carried out and identified papers categorized as (i) case-control/cohort studies associating (apparently non-syndromic) joint hypermobility and gastrointestinal involvement, (ii) case-control/cohort studies associating JHS/EDS-HT and gastrointestinal involvement, (iii) case reports/series on various gastrointestinal complications in (presumed) JHS/EDS-HT, and (iv) studies reporting gastrointestinal features in heterogeneous EDS patients' cohorts. Gastrointestinal manifestations of JHS/EDS-HT were organized and discussed in two categories, including structural anomalies (i.e., abdominal/diaphragmatic hernias, internal organ/pelvic prolapses, intestinal intussusceptions) and functional features (i.e., dysphagia, gastro-esophageal reflux, dyspepsia, recurrent abdominal pain, constipation/diarrhea), with emphasis on practice and future implications. In the second part of this paper, a summary of possible nutritional interventions in JHS/EDS-HT was presented. Supplementation strategies were borrowed from data available for general population with minor modifications in the light of recent discoveries in the pathogenesis of selected JHS/EDS-HT features.

Cytology of endoscopically obtained biopsies for the diagnosis of chronic intestinal diseases in cats.

To evaluate the diagnostic value of cytology of endoscopically obtained biopsies in cats presented for chronic gastrointestinal complaints with emphasis on the diagnosis of low-grade alimentary lymphoma (LGAL). Data of endoscopically obtained duodenal biopsies from 137 cats were evaluated retrospectively. Cytology was performed using the squash smear technique with subsequent Diff Quick® staining. Pathological findings were categorized according to type and grade of the inflammatory infiltrate. Moreover, reports were reviewed with regard to diagnosis of LGAL. Histopathology reports were analysed correspondingly and compared to cytology results. Histopathological samples were further evaluated by immunohistochemistry (IHC) if a diagnosis of LGAL had been expressed. Squash smear preparation of intestinal biopsies was adequate for cytological examination in >97% of cases. Using histopathology as gold standard, with cytology, a sensitivity and specificity for detection of a pathologic process in feline intestinal biopsies of 68.1% and 70.6% were calculated, respectively. Regarding the detection of lymphoplasmacytic (LPE) and eosinophilic enteritis a statistically significant correlation with histopathology (p<0.05) was observed. With regard to grade of the inflammatory infiltrate, a weak correlation was calculated (r=0.482). Of 21 cats diagnosed or suspected with LGAL by cytology, IHC confirmed nine cases whereas 11 cases were reclassified as LPE. None of the confirmed LGAL had been missed with histopathology. A sensitivity of 60.0% and specificity of 90.6% for cytological detection of feline LGAL was obtained. The sensitivity of cytology to diagnose LGAL is low and it has no additional significance to histological biopsies.

Gastrointestinal dysfunction in children with autism spectrum disorders.

Gastrointestinal (GI) dysfunctions are frequently reported by parents of children with autism spectrum disorders (ASD) and have been recently recognized as a comorbid condition. However, the clinical significance of these GI dysfunctions remains to be delineated. This study describes the clinical characteristics, associated comorbid disorders, and endoscopic and colonoscopic evaluation of GI dysfunction in a cohort of 164 children with ASD evaluated at a pediatric neurology practice. Symptoms of GI dysfunction were prevalent: 49% of the children reported one or more chronic GI complaints, 22% exhibited diarrhea, 26% suffered from constipation. Furthermore 13% of the parents reported their children to suffer from bloating and/or being gassy and while 10% of the parents reported vomiting or gastroesophageal reflux problems. Similar rates of GI symptoms were reported among pre-school and school-aged children. Inflammation of the gut was found in 6 of the 12 subjects who underwent endoscopic and colonoscopic evaluations, however clinical symptoms did not predict the results of the evaluation. GI dysfunction was significantly associated with sleep disorders and food intolerance, but not with irritability or aggressiveness. In summary, GI dysfunction was prevalent in this cohort of children with ASD, observations consistent with the reports of parents and other clinicians. We conclude that the GI dysfunction in ASD requires proper evaluation and treatment.

Acute abdomen due to torsion of the wandering spleen in a patient with Marfan Syndrome

Wandering spleen is a very rare defect characterized by the absence or weakness of one or more of the ligaments that hold the spleen in its normal position in the upper left abdomen. Patient symptomatology is variable and ranges from mere feeling of an abdominal lump to sudden abdominal pain due to infarction. Patients may have subacute to chronic abdominal or gastrointestinal complaints. Because of nonspecific symptoms, clinical diagnosis can be difficult; hence, imaging plays an important role. A major complication is splenic torsion, which is the cause of acute abdomen. We present a case of acute abdominal pain due to torsion of wandering spleen in a patient with Marfan Syndrome, valvular heart disease, and vertebral anomalies. Preoperative diagnosis was made on the basis of ultrasonography and computed tomography, which was later confirmed on surgery, and treated successfully.

Risk factors for MOH and chronic daily headache: an 11-year follow-up study. The Nord-Trøndelag Health Studies (HUNT)

Results Among the 51,383 participants at baseline, 41,766 were eligible approximately 11 years later. There were 26,197 participants (responder rate 63%), among whom 25,596 did not report CDH at baseline in 1995-1997. Of these, 201 (0.8%) had MOH and 246 (1.0%) had CDH without medication overuse (CDHwoO) 11 years later. The incidence of MOH was 0.72 per 1000 person-years (95% confidence interval 0.62-0.81). In the multivariate analyses, a 5-fold risk for developing MOH was found among individuals who at baseline reported regular use of tranquilizers [odds ratio 5.2 (3.0-9.0)] or who had a combination of chronic musculoskeletal complaints, gastrointestinal complaints, and Hospital Anxiety and Depression Scale score ≥11 [odds ratio 4.7 (2.4-9.0)]. Smoking and physical inactivity more than doubled the risk of MOH. In contrast, these factors did not increase the risk of CDHwoO. Conclusion In this large population-based 11-year follow-up study, several risk factors for MOH did not increase the risk for CDHwoO, suggesting these are pathogenetically distinct. If the noted associations are causal, more focus on comorbid condition, physical activity, and use of tobacco and tranquilizers may limit the development of MOH.

Is paromomycin the drug of choice for eradication of Dientamoeba fragilis in adults?

Dientamoeba fragilis is a debated protozoan parasite that is often detected in stools of patients with chronic gastro-intestinal complaints. A retrospective follow-up study of a large cohort of patients was performed to better understand the natural course of the infection and possible treatment options. D. fragilis was spontaneously cleared in 41% of untreated cases. With an eradication rate of 98%, treatment with paromomycin appeared more effective than treatment with clioquinol (83%) or metronidazole (57%).

Risk factors for medication-overuse headache: An 11-year follow-up study. The Nord-Trøndelag Health Studies

Medication-overuse headache (MOH) is relatively common, but its incidence has not been calculated and there are no prospective population-based studies that have evaluated risk factors for developing MOH. The aim of this study was to estimate incidences of and identify risk factors for developing chronic daily headache (CDH) and MOH. This longitudinal population-based cohort study used data from the Nord-Trøndelag Health Surveys performed in 1995–1997 and 2006–2008. Among the 51,383 participants at baseline, 41,766 were eligible approximately 11 years later. There were 26,197 participants (responder rate 63%), among whom 25,596 did not report CDH at baseline in 1995–1997. Of these, 201 (0.8%) had MOH and 246 (1.0%) had CDH without medication overuse (CDHwoO) 11 years later. The incidence of MOH was 0.72 per 1000 person-years (95% confidence interval 0.62–0.81). In the multivariate analyses, a 5-fold risk for developing MOH was found among individuals who at baseline reported regular use of tranquilizers [odds ratio 5.2 (3.0–9.0)] or who had a combination of chronic musculoskeletal complaints, gastrointestinal complaints, and Hospital Anxiety and Depression Scale score ⩾11 [odds ratio 4.7 (2.4–9.0)]. Smoking and physical inactivity more than doubled the risk of MOH. In contrast, these factors did not increase the risk of CDHwoO. In this large population-based 11-year follow-up study, several risk factors for MOH did not increase the risk for CDHwoO, suggesting these are pathogenetically distinct. If the noted associations are causal, more focus on comorbid condition, physical activity, and use of tobacco and tranquilizers may limit the development of MOH.

Gut Check

In Brief Many Americans have chronic gastrointestinal complaints that are not medically significant. The evidence to support the efficacy of advice from health care providers, Web sites, family, and friends is limited. The efficacy of nonpharmacological approaches to preventing and/or treating chronic constipation, irritable bowel syndrome, and gastroesophageal reflux disease is presented When it comes to gastrointestinal disorders, diet therapy often involves a lot of experimentation

Small Intestinal Bacterial Overgrowth in Patients With Lower Gastrointestinal Symptoms and a History of Previous Abdominal Surgery

The small intestinal bacterial overgrowth (SIBO) breath test has had positive results in 84% of patients with irritable bowel syndrome vs 20% of controls. We hypothesized that SIBO would be more prevalent in patients with symptoms consistent with irritable bowel syndrome who have undergone previous abdominal surgery. To identify causative factors for SIBO. Retrospective review. Tertiary colorectal surgery clinic. Result of SIBO breath test. We identified 77 patients whose differential diagnosis included SIBO from January 1, 2005, to December 31, 2007; 18 were excluded because of noncompliance with testing and 2 because of a decision to treat SIBO without formal testing. Symptoms were chronic abdominal pain in 30 patients (53%), bloating in 25 (44%), constipation in 37 (65%), and diarrhea in 7 (12%). Mean (SD) symptom duration was 45 (22) months. Of the 57 patients enrolled in this study, 45 (79%) tested positive for SIBO and 37 (82%) of those had a history of surgery, whereas 12 (21%) tested negative for SIBO and 9 (75%) of those had a history of surgery. Of the 36 SIBO-positive patients with a history of abdominal surgery (mean number of procedures, 2), the surgery locations were as follows: female reproductive organs, 23 (64%); hindgut, 15 (42%); foregut, 8 (22%); and midgut, 6 (17%). Open surgery alone was performed in 32 patients (56%) vs laparoscopic surgery in 7 (12%). Both open and laparoscopic procedures had been performed in 6 patients (11%). Four patients (7%) had a history of small intestinal obstruction. The mean age of SIBO-positive patients was higher than that of SIBO-negative patients (57 vs 44 years; P < .01). Analysis did not reveal any clinically significant independent factor associated with SIBO. Physicians should consider SIBO in the differential diagnosis of patients with normal anatomic findings and chronic lower gastrointestinal complaints.

Angioedema of the Bowel with ACE-Inhibitors: A Case Report and Systematic Review of the Literature

Purpose: Ace-inhibitor angioedema of the intestine (AIAI) of the bowel is a rare but recognized side-effect of this class of medication. Here we present an additional unpublished case report of AIAI seen at our institution and systematically review the demographics of this complication in the literature. A 38 year-old woman with hypertension, GERD, and history of H. Pylori acutely developed abdominal distention, nausea, and epigastric pain. The abdominal pain was severe, sharp, and colicky and presented in the epigastric region. The pain was accompanied by sweating, dizziness, chills, and vomiting. The pain was exacerbated by food. The patient denied any diarrhea or constipation and had started lisinopril one day prior to admission. The patient experienced a similar episode of abdominal distention with epigastric pain, nausea, and vomiting one year ago 4 days after starting lisinopril. She was subsequently hospitalized, during which the infectious workup was negative, and lisinopril was discontinued, with rapid improvement of symptoms. The CT scan of the abdomen and pelvis demonstrated markedly thickened walls of the duodenum and a 35 cm segment of middle to distal ileum, increased compared to the prior study. The patient completely recovered within 24 hours of discontinuing lisinopril. A review of 16 patients with this complication was published in 2002 (1), and an additional 20 cases (2-15) have been published since then. We found these additional cases via two MEDLINE searches. Initially we searched MEDLINE with the MESH operator “ACE-inhibitor” with the terms “bowel” and “angioedema.” We then repeated the search with keywords “ACE-inhibitor” and “angioedema.” We found a total of 587 references and excluded 572. Interestingly, of the 37 reported cases of AIAI, inclusive of the newly reported case, 32 patients (86.4%) have been women. The mechanism of AIAI is unknown. The median age has been 48 years old with a standard deviation of 12.3 years. The overall rate of angioedema is approximately 0.1-0.2% (1) and although AIAI is rare, it is important for clinicians to be aware of AIAI to avoid unnecessary testing and invasive procedures. In particular, women aged 30-60 with abdominal pain, bloating, and thickened bowel loops on imaging with a history of abdominal pain with ACE-I use may be at heightened risk. Last, several cases have involved patients on long-term ACE-I use with symptoms that have mimicked Inflammatory Bowel Disease (IBD, 13), and consideration of ACE-I angioedema may be of benefit when faced with cases of chronic lower gastrointestinal complaints.

Die systemische Mastozytose – Standortbestimmung einer internistischen Erkrankung

Systemic mastocytosis comprises disorders characterized by an accumulation of genetically altered mast cells in all organs and tissues due to an increased proliferation rate and reduced apoptosis of those pathologic mast cells. Release of their mediators can effectively influence organ function and can lead to systemic effects without inducing traces in routinely used laboratory parameters or imaging methods. In most cases, little invasive investigations allow diagnosing the disease and, hence, an appropriate therapy consisting of a basic medication with antihistamine and mast cell membrane-stabilizing compounds that should be supplemented, if required, by a medication adapted to individual symptoms, can be initiated. Because of the probably high prevalence of the disorder, systemic mastocytosis should be considered as a differential diagnosis in particular in the case of chronic gastrointestinal complaints such as abdominal pain/discomfort possibly associated with diarrhea, at an early stage.

Wandering spleen presenting as bleeding gastric varices

Ectopic spleen (splenoptosis) is an extremely rare condition in which the spleen is present in a nonanatomical position. Patients' symptomatology is variable and ranges from mere feeling of an abdominal lump to sudden abdominal pain due to infarction. Patient may have subacute to chronic abdominal or gastrointestinal complaints. Because of nonspecific symptoms, clinical diagnosis can be difficult; hence, imaging plays an important role. Presentation as a case of portal hypertension is extremely rare. We report a case of splenic torsion in a middle-aged woman who presented with hemetemesis from gastric varices secondary to chronic volvulus of an ectopic spleen. Preoperative diagnosis was made on the basis of ultrasonography, endoscopy, and computed tomography, which was later proved on surgery and treated successfully.

S1143 Non-Specific Acute Gastroenteritis Does Not Lead to Post - Infectious Chronic Gastrointestinal Complaints in the Pediatric Population: A Prospective Study

S1143 Non-Specific Acute Gastroenteritis Does Not Lead to Post - Infectious Chronic Gastrointestinal Complaints in the Pediatric Population: A Prospective Study

Assessment of Methane Breath Testing

Purpose: A positive methane breath test has been associated with constipation. Bjorneklett and Jenssen (Scand J Gastro1982; 17:985) demonstrated the presence of methane in the fasting state and in mid-day sampling (non fasting) in normal volunteers. Le Marchand et al (Environ Health Prospect 1992 Nov; 98:199–202.) demonstrated a clear circadian pattern of excretion for breath hydrogen while methane excretion was constant throughout the day. Aim: To assess change in methane from baseline following lactulose dosing. Methods: One hundred ninety-nine patients were referred to the OFDR gastrointestinal physiology laboratory with chronic lower gastrointestinal complaints for testing for bacteria overgrowth between 8/11/2005 and 6/8/2007. Patients were stratified by baseline methane values: < 2 ppm negative, 2–9 ppm low methane producers, >10 ppm high methane producers. Early in our experience, methane breath test was considered complete if the baseline CH4 was elevated (N = 15) (no lactulose was given and no other samples were taken). The remaining 184 patients were given 10 g lactulose orally. Methane and hydrogen in the exhaled breath was measured every ten or fifteen minutes for three hours using Quintron microlyser. Results: The data is summarized in the table. None of the 149 patients with no measurable methane became positive after lactulose ingestion. When the initial breath was positive for methane, patient could have an increase, decrease, or fluctuation in breath methane. No patients had a decrease in methane during the study. 15 were discontinued as mentioned above.TableThe above table did not include 3 patients (discontinued because of high H2) Conclusion: 1) An initial BT with low positive methane did not show an increase in methane following lactulose; 2) An initial BT with high positive methane increases with lactulose 50% of the time. 3) A negative methane breath test does not become positive after lactulose. Conclusion 1) Lactulose administration has little effect on baseline breath methane values. 2) 25% of our patient population have positive tests for breath methane.

Immune dysfunction in Camurati-Engelmann disease

Rationale Camurati-Engelmann disease (CED) is a progressive, autosomal dominant sclerosing bone dysplasia involving gene mutation of the latency-associated peptide of tumor growth factor (TGF)-β1, preventing inactivation of the cytokine. Since TGF-β is thought to play a regulatory role in immunity, one might expect an immune dysfunction in CED. Methods By retrospective chart review, a mother and daughter with CED were identified. Results The mother had a history of asthma, chronic gastrointestinal complaints, tobacco use, recurrent conjunctivitis, urinary tract infections, vaginal yeast infections, and monthly bronchitis. She had normal IgG and IgA, low IgG2, normal IgG4, low IgM of 48 (normal 60-263 mg/dl), and high IgE of 1709 (normal 2-120 IU/ml). However, she had inadequate anti-polysaccharide antibody response, anergy by DTH skin testing, and no response to recall antigens in vitro. She had normal serum TGF-β, but elevated serum IFN-γ, IL-4, and TNF-α. The daughter had documented CED gene mutation, bone pain, fatigue, loss of appetite, recurrent bronchitis and pharyngitis, requiring multiple courses of antibiotics. She had normal IgG and IgA, normal IgG subclasses, low IgM of 55, increased IgE of 192, normal anti-polysaccharide antibody response, and normal in vitro lymphocyte testing, but anergic DTH skin testing. Unlike her mother, she had non-detectable serum cytokine levels. Conclusions These patients reflect that gene mutation of the TGF-β1 latency-associated peptide is associated with immune dysfunction. Individual differences in immune abnormalities may parallel the variable, and progressive, bone manifestations seen in these patients. We anticipate the daughter's immune dysfunction to become more overt with age.

Polypectomy of Esophageal Polyp Due to Esophagitis

Esophageal polyp can be found by chance during endoscopic examination. Polyps can be formed by changes in the esophageal mucosa due to reflux esophagitis. We report a case of multiple esophageal polyp in a patient with complaints of recurrent regurgitation without heartburn. Endoscopy demonstrated multiple polyps at the distal esophagus. Anatomic pathology evaluation of the polyp demonstrated mucosa lined with squamous epithels demonstrating elongation of the papilla and deposition of acute and chronic inflammatory cells, indicating chronic esophagitis with hyperplastic epithels. In this case, we conducted recurrent ligation of the multiple polyps. Evaluation at 2 weeks after the final ligation demonstrated no polyp remains, and the post-ligation ulcer was found. Evaluation at 1 month following treatment found diminished complaints. From this case, we can conclude that endoscopy is an important investigation modality to establish the diagnosis in cases of chronic gastrointestinal complaints. Ligation is a choice for the management of esophageal polyps. Key words : Esophageal polyp, polipectomy, ligation

Laboratory Diagnosis forGiardia LambliaInfection: A Comparison of Microscopy, Coprodiagnosis and Serology

To evaluate newer techniques such as coproantigen detection and serology in the diagnosis of symptomatic Giardia lamblia infection. Blinded comparison of copro-antigen detection (by ELISA), serology (immunoglobulin IgG and IgM anti-G lamblia by ELISA, and IgG, IgM and IgA by immunoblot) and microscopy in clinical samples. Microscopic findings for three preserved stools were considered the gold standard. Travel medicine clinic. Adults, post-travel, with gastrointestinal symptomatology. For 152 previously collected stools, copro-antigen detection had a sensitivity of 73 of 74 (98.6%) and a specificity of 78 of 78 (100%). In clinical samples of 62 patients, eight of the 62 patients (13%) were diagnosed with G lamblia infection on microscopy. Copro-antigen diagnosis was accurate in symptomatic patients, with sensitivity of seven of eight (87.5%) and specificity of 52 of 54 (96.8%). Serology was less accurate. IgG response to G lamblia had sensitivity of four of seven and specificity of 24 of 50 (48%), and IgM response had sensitivity of three of six and specificity 27 of 48 (56%). Western blot had a sensitivity of five of seven and a specificity of 38 of 49 (78%). Copro-antigen diagnosis of G lamblia is highly accurate in patients with chronic gastrointestinal complaints, while serology is less accurate and appears to be less useful diagnostically.

Cryptosporidiosis and blastocystosis in renal transplant recipients.

Some intestinal parasitic infections are frequently seen in renal transplant recipients. Parasites such as Cryptosporidium spp. and Blastocystis hominis are often asymptomatic or responsible for limited infections in normals, but may cause prolonged and heavy infections with gastrointestinal complaints, mainly diarrhea, in immunocompromised patients. Such infections can often not be detected by routine diagnostic procedures, but special concentration and staining methods are needed. We investigated 115 fecal specimens from 69 renal transplant recipients and 42 fecal specimens from 42 control cases. Of the 69 recipients, 27 (39.1%) had B. hominis and 13 (18.8%) had Cryptosporidium spp. in at least one fecal specimen. Prevalence of symptomatic Cryptosporidium infections was significantly higher in the renal transplant recipients, when compared with the control group (p < 0.05). Special parasitological procedures must be performed in immunocompromised patients with chronic gastrointestinal complaints. Disappearance of symptoms after antiparastic drugs in some of 16 symptomatic patients are described, suggesting that these infections are more pathogenic in transplant recipients.

Gastrointestinal pathology in patients with common variable immunodeficiency and X-linked agammaglobulinemia.

Review of the medical records of 43 patients with common variable immunodeficiency (CVID) and 23 patients with X-linked agammaglobulinemia (XLAG) revealed a high incidence of chronic gastrointestinal complaints, most commonly diarrhea. Thirty-eight biopsies, four small-bowel resection specimens, and one autopsy from 10 patients with CVID and one patient with XLAG showed a wide range of abnormalities. A pattern resembling acute graft-versus-host disease, with apoptotic bodies and lymphocytes in crypts, was seen in the stomach (four patients), small bowel (three patients), and colon (three patients). Small-bowel specimens from three CVID patients with malabsorption showed mild to severe villous atrophy. Three CVID patients had Giardia in biopsies. Two cases of small bowel lymphoma associated with nodular lymphoid hyperplasia were identified in CVID patients. One patient's small bowel contained foamy histiocytes in the lamina propria, resembling Whipple's disease or chronic granulomatous disease, with numerous apoptotic bodies in crypts. Ultrastructurally, the histiocytes contained cellular debris. The patient with XLAG had recurrent fissuring necrosis of small bowel resembling Crohn's disease; a patient with CVID had colitis with features similar to ulcerative colitis. Poorly formed granulomas were seen in the stomach (one CVID patient) and the colon (two CVID patients). Lymphocyte populations were dominated by T cells; B cells were scarce except in lymphoid follicles in CVID patients with nodular lymphoid hyperplasia. Patients with CVID and XLAG manifest a spectrum of abnormalities in the gastrointestinal tract, with patterns superficially resembling graft-versus-host disease, inflammatory bowel disease, and Whipple's disease, but often lacking some of the diagnostic features of the diseases. Many of the CVID patients with chronic gastrointestinal complaints (62%) also had evidence of autoimmune phenomena, suggesting that in some patients the inflammatory process in the gastrointestinal tract has an autoimmune component.

Management of the Severely Demented Patient

To the Editor.— A recent article on medical ethics by L. R. Kass (1983; 249:1305) prompted this letter concerning the wisdom and propriety of treating demented patients. Report of a Case.— An 87-year-old demented woman was hospitalized with acute and chronic gastrointestinal (GI) complaints, primarily lower abdominal pains, which she had had for 40 years. Results of a comprehensive examination were normal, including upper GI tract series, upper GI tract panendoscopy, abdominal EMI scan, barium enema examination, and sigmoidoscopy. A psychiatric consultation was requested to evaluate her dementia. She was out of touch with reality and had generalized slowing on her EEG and generalized, moderately severe cerebral atrophy on the EMI scan of her head. Comment.— This case raises the question of whether it is proper to order so complete a workup on a severely demented patient. The internist was looking for a bowel carcinoma, the third leading cause of