Evidence Of Gastrointestinal Bleeding Research Articles

Intravenous esomeprazole pharmacodynamics in critically ill patients

Objective:A widely held belief contends that food-induced proton pump activation is important for optimal proton pump inhibitor–induced inhibition of gastric acid secretion. This study was undertaken to assess intragastric acid control with intravenous (IV) esomeprazole in critically ill patients.Research design and methods:This open-label, single-arm, exploratory trial was conducted at five university or regional hospital intensive care units in the US. Adult patients admitted to an intensive care unit who required mechanical ventilation and had at least one additional risk factor for stress-induced ulcer received twice-daily IV esomeprazole 40 mg for 48 hours and could continue for another 24 hours if no prepyloric enteral feedings were planned.Clinical trial registration:Trial registration: ClinicalTrials.gov identifier: NCT00428701.Main outcome measures:The primary efficacy variable was the linear-interpolated percentage of time intragastric pH was ≥4 during 24–48 hours. Secondary efficacy variables included the interpolated percentage of time intragastric pH was ≥4 during 0–24, 0–48, and 48–72 hours, the percentage of gastric aspirates collected with pH ≥4 during 0–24, 24–48, 0–48, and 48–72 hours, and time to stable pH ≥4. Safety was assessed based on adverse events (AEs), physical examinations, vital signs, laboratory tests, and electrocardiograms.Results:Forty-five patients were enrolled (one was excluded because of previous partial gastrectomy). Interpolated mean percentage time pH ≥4 was 88.8%, 80.7%, and 83.5% for 24–48, 0–24, and 0–48 hours, respectively. For 0–72 hours, ≥78% of gastric aspirates had pH ≥4. Median time to stable pH was 1 hour (95% confidence interval: 0.67, 2.00). Treatment was well tolerated, with no evidence of gastrointestinal bleeding. A total of 75 AEs occurred in 34 patients, none considered treatment related.Conclusions:In this noncontrolled exploratory study, twice-daily IV esomeprazole 40 mg rapidly decreased intragastric acidity and effectively maintained pH ≥4 during 0–72 hours in fasting, critically ill, mechanically ventilated patients at high risk for stress ulcers.

Active gastrointestinal bleeding: evaluation with contrast-enhanced ultrasonography

Advances in contrast-enhanced ultrasonography (CEUS) have made it possible to detect leakage of contrast medium. The aim of the present study was to prospectively evaluate the efficacy of CEUS for depiction of active gastrointestinal (GI) bleeding. Eighty-nine patients (50 men and 39 women with a mean age of 68.6 years) who had evidence of GI bleeding were enrolled. After injection of Sonazoid, CEUS was performed for 2 min. Evidence of active GI bleeding was defined as positive when pooling or leakage of contrast medium was observed in the GI tract. Calculation of the sensitivity, specificity, positive and negative predictive values, and the positive and negative likelihood ratio (LR) for depiction of active GI bleeding by CEUS was done by comparison with GI endoscopy. The sensitivity, specificity, positive predictive value, and negative predictive value of CEUS for detection of active GI bleeding were 73.7% (95% CI: 48.8, 90.9), 97.1% (95% CI: 90.0, 99.7), 87.5% (95% CI: 61.7, 98.4), and 93.2% (95% CI: 84.7, 97.7), respectively. The positive LR and negative LR were 25.4 and 0.27, respectively. CEUS is highly effective for the detection of active GI bleeding.

Capsule Endoscopy in Patients with Low Neutrophil Count and Evidence of Gastrointestinal Bleeding

Background and Aim: The utility and safety of capsule endoscopy (CE) in patients with low neutrophil count and gastrointestinal bleeding is unknown. The aim of this study was to determine the yield and safety of CE in this patient population. Methods: A retrospective analysis of 225 patients who underwent CE at M.D. Anderson Cancer Center from July 2005 thru September 2008. Patients with gastrointestinal bleeding who had an absolute neutrophil count (ANC) <1500 cells/μL during the time of capsule endoscopy were identified.

Acute Hemobilia and Hemocholecyst in 2 Dogs with Gallbladder Carcinoid

Acute Hemobilia and Hemocholecyst in 2 Dogs with Gallbladder Carcinoid

Clinical Significance of Colonoscopic Findings Associated With Colonic Thickening on Computed Tomography

To determine the utility of colonoscopy in the management of patients with abdominal pain found to have colonic thickening on computed tomography (CT). CT is often used in the investigation of abdominal pain. Clinical guidelines regarding colonoscopy when colonic wall thickening is reported at CT are lacking. From July 2000 to April 2004, the abdominal CT reports of all patients at a major teaching hospital who were investigated for abdominal pain were reviewed. Cases were selected if any colonic wall thickening was reported. Patients were excluded if they had a previously diagnosed gastrointestinal condition, or if they had not undergone colonoscopy within 30 days of the abnormal CT. Clinical, endoscopic, and pathologic data were extracted from the medical records of all eligible patients. One hundred seven cases were identified. Of these, 8 (7.4%) had colorectal adenocarcinoma. In 10 patients (9.3%), a new diagnosis of inflammatory bowel disease (IBD) was made. Sixteen (15.0%) had findings consistent with infectious colitis, 39 (36.4%) ischemic colitis, and 6 patients (5.6%) had miscellaneous findings possibly responsible for the colonic thickening (diverticulitis, appendicitis, proctitis, and melanosis coli). In 28 patients (26.1%), no abnormality was found that could explain the CT finding. Of those diagnosed with colorectal carcinoma or IBD, only 4 of the 18 patients (28%) presented with evidence of gastrointestinal bleeding or anemia. On the basis of the rate of new diagnoses of colorectal carcinoma and IBD, we recommend colonoscopy be performed after clinical evaluation in patients with abdominal pain and colonic thickening on CT.

The Prevalence of Advanced Colonic Neoplasia among Women Aged 50–59 yr Undergoing Average-Risk Screening Colonoscopy

Purpose: Advanced neoplastic lesions in colon are considered more clinically relevant lesions as they have a higher likelihood of progressing to colorectal cancer compared to smaller or hyperplastic lesions. Among the persons who are above 50 years of age, women in 50–59 years age group are reported to have the lowest prevalence of advanced neoplasia. The aim of this study was to determine the prevalence of advanced neoplasia in asymptomatic, average-risk women in 50–59 year age group. Methods: This is a retrospective cohort study of consecutive asymptomatic women aged 50– 59 yr, who underwent average- risk screening colonoscopy. Women with evidence of gastrointestinal bleeding, anemia or previous history of adenomatous polyps and family history of colon cancer were excluded. Colonoscopy and pathology reports were reviewed to obtain data regarding the number, size and histology of the polyps. Advanced neoplastic lesions were defined as tubular adenoma measuring 1cm or larger or any polyp with villous histologic characteristics, high-grade dysplasia, or cancer. The diameter of the polyp was determined based on both visual estimate per the endoscopy report and gross specimen size per pathology report. If there is discrepancy between these two reports regarding the size of a polyp, smaller size was chosen to avoid overestimation of the size. The prevalence of histopathologcal findings was determined by classification of patients according to their most advanced lesion. Results: A total of 1116 persons underwent average-risk screening colonoscopy during the 13-month study period (May 2005 to May 2006). Among them, 498 (45%) were women, and 56% of them (280 of 498) were between 50 and 59 years of age. Overall prevalence of colorectal neoplasia was 25% (70 of 280 women) in the 50–59 age-group. Non-advnaced adenomatous polyps were found in 56 women (20%) and advanced neoplasia was found in 14 women (5%). Conclusions: 1) The point prevalence of advanced neoplasia among women aged 50–59 yr in our cohort is higher than previously reported and is similar to that of men in the same age group from other studies. 2) The overall prevalence of advanced neoplasia in women in 50–59yr age group is still comparatively low. 3) Risk stratification to identify this sub-group of persons at risk will lead to optimal colonoscopy resource utilization.

American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia

American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia

When to Feed the Patient With Gastrointestinal Bleeding

Whether to provide artificial enteral nutrition therapy to a patient with evidence of gastrointestinal bleeding (GIB) creates a difficult clinical dilemma. Concern that enteral feeding may contribute to the morbidity associated with GIB leads to delays in initiating enteral therapy or to cessation of feeding in the patient in whom artificial nutrition support has already been started. Surprisingly, evidence of GIB is not an automatic contraindication to further enteral feeding. Depending on the etiology of the GIB, enteral nutrition may protect the gut mucosa and reduce further bleeding in some patients, actually increase risk for rebleeding in other patients, or serve as a moot point with no relation to further bleeding or morbidity in still other patients. In many cases, an endoscopic evaluation is needed to distinguish the differential etiology of the GIB. The nutrition support specialist needs a full understanding of the physiology behind the varying diagnoses for GIB to know whether feedings can be initiated or continued or whether enteral feedings need to be withheld for 48-72 hours until risk for rebleeding and further morbidity is minimized.

The Diagnostic Value of Gastrointestinal Endoscopy in Anemic Patients with Low Normal Ferritin Level.

Purpose: Our objective is to investigate the yield of upper and lower gastrointestinal(GI) endoscopic evaluations in anemic patients with serum ferritin levels between 40 and 100 ng/ml.Subjects and Methods: Most practice guidelines recommend endoscopic evaluation of the GI tract in men and post menopausal women with anemia and a serum ferritin level less than 20–40 ng/ml. However, as ferritin is an acute phase reactant, iron deficiency anemia (IDA) can be present with ferritin greater than 40 ng/ml. The diagnostic yield of GI endoscopy in patients with anemia, no GI symptoms or signs, and low normal ferritin. Some patients at the Veterans Affairs (VA) Connecticut Healthcare System undergo endoscopic evaluation as part of their anemia work up even when the ferritin is in the low normal range (40–100 ng/ml). We retrospectively reviewed the data on this population of patients over a 42-month period (1999–2003) to determine the incidence of GI findings.Results: All 522 patients who had undergone endoscopic examination for anemia over a 42 month period were screened. We identified 54 male patients who had a serum ferritin level between 40 and 100 ng/ml, no GI symptoms, and no evidence of GI bleeding. Significant lower GI findings, including large tubular adenomas and arterio-venous malformation (AVM), were identified in 3/53 cases (6.7%). Upper GI findings, including malignancy, peptic ulcers, Helicobacter Pylori gastritis, and AVM, were found in 14/47(30%) of cases.Conclusion: In this retrospective study on male anemic patients with low normal serum ferritin but lack of GI symptoms or known bleeding, the prevalence of upper and lower GI lesions was 30% and 6.7%, respectively. Our study supports a GI endoscopic evaluation in anemic patients with ferritin between 40 to 100 ng/ml, even in the absence of GI symptoms, or evidence for GI bleeding.Table 1: Ferritin, hematocrit (HCT), mean corpuscular volume (MCV) and prevalence of GI lesions in patients with borderline ferritin levelsTotal number of pateientsN=54Age(YO)72.4±10.3Ferritin (ng/ml)63.6±16.7HCT(%)35.5% + 2.4 (range 34–40%)MCV(fL)85.9±7.6Upper GI findings17/47Lower GI findings22/53* In the majority of the patients, more than one serum ferritin level was measured, and the one closest to the endoscopic procedure was used.Table 2: Endoscopic Findings in Anemic Patients with Serum Ferritin Levels between 40–100 ng/mL without significant GI symptoms or signs.LOWER GI FINDINGSNumber/percentageMALIGNANCY0/53ADENOMA>1CM2/53ADENOMA<1CM15/53*EXTENSIVE DIVERTICULOSIS4/53ARTERIOVENOUS MALFORMATION1/53ULCER0/53UPPER GI FINDINGSMALIGNANCY1/47ESOPHAGITIS/BARRETT'S ESOPHAGUS1/47LARGE HIATAL HERNIAS WITH EROSION2/47ESOPHAGEAL VARICES1/47CHRONIC ACTIVE GASTRITIS/DUODENITIS, H PYLORI+5/47GASTRIC OR DUODENAL PEPTIC ULCER5/47ARTERIOVENOUS MALFORMATION1/47ATROPHIC GASTRITIS1/47TA = tubular adenoma. *In 13/15 cases, TAs were found proximal to the splenic flexure, in 6/15 cases multiple TAs were found.

Aging, the gastrointestinal tract, and risk of acid-related disease

It is estimated that by 2020, >16% of people in the United States will be ≥65 years of age and that nearly 20 million will be >85 years of age. Aging imparts a variety of physiologic changes in the oropharynx, esophagus, and stomach that increase the risk for esophageal and gastrointestinal disorders. Older individuals also tend to have a higher prevalence of comorbid factors, such as Helicobacter pylori infection, smoking, presence of other diseases, or use of medications (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs]) that increase their risk for acid-related disorders. Given these physiologic and comorbidity factors, the elderly are at higher risk for gastroesophageal reflux disease (GERD), pill-induced esophagitis, peptic ulcer disease, and complications related to the use of NSAIDs. Unfortunately, in the elderly patient with these disorders—even those with severe disease or complications—symptom presentation may be subtle or atypical, resulting in a delayed diagnosis. Endoscopy remains the “gold standard” for the identification of mucosal disease and should be performed in all patients with “new-onset” or persistent symptoms who are >45 years of age, as well as in individuals of any age who present with alarm symptoms, such as weight loss, vomiting, anemia, dysphagia, or evidence of gastrointestinal bleeding. In general, the treatment of older individuals with peptic ulcer or GERD and its complications is similar to that of younger individuals. Proton pump inhibitors are the mainstay of therapy for symptom relief, healing of erosive esophagitis, resolution of peptic ulceration, reduction of the risk for NSAID-induced mucosal damage, and prevention of disease recurrence.

Clinical value of in vitro labeling of red blood cells with technetium 99m-scintigraphy in the detection of acute gastrointestinal bleeding

We evaluate the clinical value of in vitro labeling of red blood cells with technetium 99m (99mTc-RBC) scintigraphy for the detection of gastrointestinal (GI) bleeding sites. Ten patients referred with clinical evidence of GI bleeding and negative colonoscopy underwent 99mTc-RBC scintigraphy after endovenous administration of 925 MBq (25 mCi) 99mTc-RBC labeled by a simple technique, previously described by ourselves. Dynamic images of the abdomen were taken at 10 s intervals for 40 min. Then, 5 min images were obtained 1, 3 and 5 hours after cell administration. Delayed images up to 24 hours were obtained when early results were negative. All the patients with suspected GI bleeding were confirmed to have active hemorrhage up to 24 hours. The identification of bleeding sites was 40% (40 min), 20% (60 min) and 30% up to 24 hours. Of the nine patients with definite active hemorrhage, the bleeding sites were identified by surgery in all of them; and in the remaining patient, without active hemorrhage, the bleeding site was not identified by surgery. In conclusion, the simplicity, reproducibility and reliability of this technique of in vitro labeling of red blood cells, particularly when bleeding rates are low and intermittent, make it, in our point of view, the first line of investigation in any patient with suspected bleeding from the colon or upper GI tract if endoscopic evaluation is not possible in the latter.

Flexible sigmoidoscopy plus air-contrast barium enema versus colonoscopy for evaluation of symptomatic patients without evidence of bleeding

One hundred forty-nine patients aged 40 years or more with symptoms suggestive of colonic disease but without evidence of gastrointestinal bleeding (absence of hematochezia, normal serum levels of hemoglobin, and at least one test negative for fecal occult blood) were randomized to undergo either initial colonoscopy or initial flexible sigmoidoscopy plus air-contrast barium enema. Patients with incomplete initial colonoscopy and certain patients with polyps seen on flexible sigmoidoscopy plus barium enema underwent the alternative procedure (barium enema or colonoscopy). The main results were as follows: First, the overall prevalence of cancer in the study was very low (0.67%). Second, initial flexible sigmoidoscopy plus barium enema detected more patients with diverticulosis than did initial colonoscopy (46% versus 31%; p = .01). Initial colonoscopy detected more persons with adenomas ( p = .06) than did initial flexible sigmoidoscopy plus barium enema. Patients undergoing initial flexible sigmoidoscopy plus barium enema were more likely to require the alternative procedure (24%) than were patients undergoing initial colonoscopy (6%; p = .002). Third, sensitivity analyses suggested that for most areas in the United States, initial colonoscopy would be more cost-effective for the outcomes of detection of adenomas and detection of large adenomas, although very few patients in the study had large adenomas. We conclude that the prevalence of colorectal cancer in persons with colonic symptoms but no evidence of bleeding is low and is comparable with the prevalence in an asymptomatic population. Cost-effective selection of imaging strategies in this population can be based on demographic factors such as age and sex, which are better predictors of the presence of adenomas than are symptoms. (Gastrointest Endosc 1995;42:132-8.)

Secondary aortoenteric fistula: Contemporary outcome with use of extraanatomic bypass and infected graft excision

The standard treatment for secondary aortoenteric fistula (SAEF) has been infected graft removal (IGR) and extraanatomic bypass (EAB), an approach criticized for its high rate of death, amputation, and disruption of aortic closure. Recently, graft excision and in situ graft replacement has been proposed as a safer treatment alternative. Because the current outcome that can be achieved by use of the standard treatment of SAEF has really not been established, we reviewed the records of 33 patients treated for SAEF at our institution during a contemporary time interval (1980 to 1992). Thirteen patients (39.4%) were admitted with evidence of gastrointestinal bleeding and infection, whereas nine (27.3%) only had bleeding, 10 (30.3%) only had signs of infection, and one SAEF was entirely occult (graft thrombosis). Four patients required emergency operation. The fistula type was anastomotic in 13 (39.4%) patients, paraprosthetic in 15 (45.5%), and not specified in 4 cases. Thirty-two patients underwent EAB followed immediately by IGR (n = 16, 48.5%) or followed by IGR after a short interval, averaging 3.9 days (n = 16, 48.5%). The final patient underwent IGR, followed by EAB. Follow-up on 31 patients (93.9%) averaged 4.4 +/- 3.7 years. There were nine deaths (27.3%) resulting from the SAEF, six perioperative and three late. Three patients (9.1%) had disrupted aortic closure. There were four amputations in three patients (9.1%), two perioperative and two late. Late EAB infection occurred in five patients (15.2%), leading to one death and one amputation. EAB failure occurred in six patients, two during operation and four late, leading to one amputation. The cumulative cure rate for this SAEF group was 70% at 3 years and thereafter. Compared with our earlier SAEF experience, this is a decline of 21% in the mortality rate, 19% in aortic disruption, and 27% in limb loss. We conclude that outcome reports based on SAEF series extending over long time intervals do not accurately represent the results that are currently achieved with standard SAEF treatment with use of EAB plus IGR. This improved outcome is attributed to wide debridement of infected tissue beds, reduced intervals of lower body ischemia, and advances in perioperative management. To determine whether any new treatment approach actually offers improved outcome in the management of SAEF, comparison with EAB plus IGR should be limited to patients treated within the last decade at most.

Diagnostic value of a guaiac occult blood test and faecal alpha 1-antitrypsin.

This study evaluates the diagnostic accuracy of a faecal occult blood test and faecal alpha 1-antitrypsin in the investigation of patients with gastrointestinal symptoms or iron deficiency anaemia. One hundred and seventy nine patients with either iron deficiency anaemia (n = 67), changed bowel habit and aged > 39 years (n = 107), or a history suggestive of melaena (n = 5) provided faecal samples. After investigation, 32 patients had a diagnosis of possible gastrointestinal bleeding and 139 patients had no evidence of gastrointestinal bleeding. Eight patients had a cause of enteric protein loss in the absence of gastrointestinal bleeding and were excluded from subsequent analysis. The faecal alpha 1-antitrypsin test was diagnostically more accurate than the guaiac test in identifying probable gastrointestinal bleeding (82% and 72% respectively, p < 0.05). This faecal alpha 1-antitrypsin test was also more specific (83% and 72% respectively, p < 0.05), but was not significantly more sensitive (78% and 72% respectively). The sensitivity of these tests was insufficient to recommend their use for most patients in this study.

Gastrointestinal bleeding during an ultramarathon

A prospective study was undertaken to determine the frequency of detectable gastrointestinal bleeding in participants of a 100-mile running race. Pre- and postrace questionnaires were utilized to determine training data, gastrointestinal symptoms, diet, and the use of medications during training and during the race, prior known gastrointestinal disease, and 100-mile race experience. Three prerace and the first three postrace stools were sampled for blood using the standard Hemoccult method in 35 runners: 85% of the participants who were Hemoccult negative before the race converted to positive in their postrace samples. Runners with the postrace Hemoccult-positive stools had more frequent and intense nausea, diarrhea, abdominal cramping, and bloating (P less than 0.05) during the race. Lower gastrointestinal symptoms correlated with Hemoccult positivity (P less than 0.05), whereas upper gastrointestinal symptoms did not. The majority of participants showed evidence of gastrointestinal bleeding after the race. Digestive symptoms are common and lower gastrointestinal symptoms correlate with gastrointestinal bleeding.

Gastrointestinal tract involvement by prosthetic graft infection. The significance of gastrointestinal hemorrhage.

To investigate the patterns of interaction between vascular graft complications and the gastrointestinal (GI) tract, the incidence, pattern, and cause of GI bleeding among patients treated for secondary aortoenteric fistula (AEF) or chronic perigraft infection (PGI) was reviewed. Among 110 patients with infected grafts, there were 39 with secondary AEF and 71 chronic PGI. GI hemorrhage occurred in 24 AEF patients (61.5%), five PGI patients (9.4%) with aortoiliofemoral grafts (PGI-AIF), and in no PGI patients with peripherally located grafts (PGI-Other). The incidence of acute and chronic bleeding patterns was the same in both AEF and PGI patients. All GI bleeding in PGI patients was from the upper GI tract, whereas lower GI hemorrhage predominated slightly among AEF patients. Endoscopy was often negative among AEF patients (10 of 17) but always diagnosed the etiology of bleeding in PGI patients (gastritis in four; duodenal ulcer in one). Fifteen AEF patients (38%) had no evidence of GI bleeding at any time during evaluation. Acute hemorrhage among AEF patients was usually associated with an anastomotic fistula (10 of 14), while paraprosthetic fistulas often did not bleed (6 of 10) or bled chronically (12 of 15). Sepsis occurred significantly more often among AEF patients (8 of 39, 21%) than among PGI patients (2 of 71, 3.0%). However, there was no significant difference in the incidence of sepsis or systemic infection between PGI-AIF patients and PGI-Other patients. In summary, gastrointestinal involvement by prosthetic graft infection may be either direct (fistula formation), indirect (sepsis/infection induced stress gastritis or ulceration), or silent. No absolute correlation exists between GI hemorrhage and the presence or absence of a graft-enteric fistula. Endoscopic demonstration of nonfistula GI pathology does not exclude the presence of graft infection. Recognition of these patterns of GI tract involvement by vascular graft infection may facilitate prompt diagnosis and improve treatment results.

Enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients.

The incidence of upper gastrointestinal (GI) bleeding in mechanically ventilated ICU patients receiving enteral alimentation was reviewed and compared to bleeding occurring in ventilated patients receiving prophylactic antacids or cimetidine. Of 250 patients admitted to our ICU during a 1-yr time period, 43 ventilated patients were studied. Patients in each group were comparable with respect to age, respiratory diagnosis, number of GI hemorrhage risk factors, and number of ventilator, ICU, and hospital days. Twenty-one patients had evidence of GI bleeding. Fourteen of 20 patients receiving antacids and 7 of 9 patients receiving cimetidine had evidence of GI bleeding. No bleeding occurred in 14 patients receiving enteral alimentation. Complications of enteral alimentation were few and none required discontinuation of enteral alimentation. Our preliminary data suggest the role of enteral alimentation in critically ill patients may include not only protection against malnutrition but also protection against GI bleeding.

Barium enema: An outpatient procedure in the early diagnosis of acute appendicitis

Both of our patients, young girls with ulcerative colitis, developed the onset of fever, vomiting, and bloody diarrhea after the ingestion of SAS. We believe that these symptoms were not secondary to the underlying ulcerative colitis because they were reproducible in each patient and resolution was more rapid than could be expected with ulcerative colitis. Patient 1 presented with symptoms characteristic of ulcerative colitis. When treated with SAS her condition deteriorated and did not improve until the SAS was discontinued. Symptoms returned during two subsequent challenges although she was clinically well on both occasions and in complete remission on one. Similarly Patient 2 developed symptoms each time she was treated with SAS. Her colitis was quiescent at the time of each challenge. Both patients tolerate aspirin without evidence of gastrointestinal bleeding or upset. Numerous side effects have been reported with both sulfonamides and salicylates, but the combination of fever, vomiting, and bloody diarrhea has not been among them 8. 9 nor has bloody diarrhea been previously reported with SAS. 1~ We have no explanation for the toxicity observed in our patients. Physicians caring for patients with inflammatory bowel disease should be aware that the onset of fever, vomiting, and bloody diarrhea may be due to SAS and not to a flare-up of the disease. REFERENCES 1. Misiewicz J J, Lennard-Jones JE, Connell AM, Baron JH, and Avery Jones F: Controlled trial of sulfasalazine in maintenance therapy for ulcerative colitis, Lancet 1:185, 1965. 2. Goldman P, and Peppercorn MA: Sulfasalazine, N Engl J Med 293:20, 1975. 3. Das KM, Eastwood MA, McManus JPA, and Sircus W: Adverse reaction during salicylazosulfapyridine therapy and the relation with drug metabolism and acetylator phenotype, N Engl J Med 289:491, 1973. 4. Block MB, Genant HK, and Kirsner JB: Pancreatitis as an adverse reaction to salicylazosulfapyridine, N Engl J Med 282:380, 1970. 5. Lead Article. Sulfasalazine induced lung disease, Lancet 2:504, 1974. 6. Wallace IW: Neurotoxicity associated with a reaction to sulfasalazine, Practitioner 204:850, 1970. 7. Strom J: Toxic epidermal necrolysis (Lyell's Syndrome) Scand J Infect Dis 1:209, 1969. 8. Woodbury DM, and Fingl E: Analgesic, antipyretics, antiinflammatory agents and drugs employed in the therapy of gout, in Goodman A, and Gilman AG, editors: The pharmacological basis of therapeutics, New York, 1975, The Macmillan Company, pp 325-358. 9. Weinstein LS: Antimicrobial agents, sulfonamides and trimethoprimsulfmethoxazole, in Goodman A, and Gilman AG, editors: The pharmacologic basis of therapeutics, New York, 1975, The Macmillan Company, pp 1113-1129. 10. Schinagl EF: Pharmacia Laboratories Inc., Personal communication.

Operable Breast Carcinoma Associated With Refractory Anemia

A WOMAN with undiagnosable anemia was cured when a localized breast cancer, necrotic and surrounded by an inflammatory reaction was removed by radical mastectomy. Report of a Case A 47-year-old woman was referred for diagnosis of fatigue and anemia of approximately one year's duration. She had been treated with cyanocobalamin injections and oral iron therapy, without hematological response. Except for cholecystectomy and surgery for anal fistula, her health had been good. There was no history of drug ingestion, except for the hematinics, or toxic exposure. Family history was negative for hematolotic disease, and there was no history or evidence of gastrointestinal bleeding or menorrhagia. Results of physical examination were normal except for the findings of pallor and a firm 4-cm mass in the upper outer quadrant of the right breast. Results of laboratory studies included a red blood cell (RBC) count of 4.22 million/cu mm, a hemoglobin level of 8.7

Abdominal Pain in Schönlein-Henoch Syndrome

It is almost 100 years since Henoch reported the association of abdominal pain, joint pains, and a skin rash in children. Abdominal pain or evidence of gastrointestinal bleeding is present in approximately two thirds of the patients in large series with Schonlein-Henoch (S-H) syndrome. 1-3 It is therefore surprising that so little investigation of the classic abdominal colic has been done. Historical Review Robert Willan, an English physician, in 1808, was the first to describe a patient with swollen, painful joints and a rash. However, the condition was not recognized as an entity until Schonlein, in 1837, observed that these joint symptoms were accompanied by a red macular rash. He also noted that a preceding upper respiratory infection (URI) was common. Henoch, in 1874, reported four children with rashes, bloody diarrhea, and painful joints. The rash was characterized by red macules, and at time purpura. The frequent association of nephritis