Frequent Episodes Of Vomiting Research Articles

Mallory-Weiss Syndrome with Oesophageal Tear: A Case Report

A 67-year-old male patient presented to the hospital with complaints of mild-grade fever, gradually progressive cough, and frequent episodes of vomiting. The initial diagnosis was acute gastritis with severe dehydration. The patient had a medical history of Type 2 Diabetes Mellitus (T2DM) for 2 years and Hypertension (HTN) for 20 years, for which he was already receiving treatment. Due to continuous bleeding, an urgent endoscopy was performed, revealing a linear tear in the mucous membrane of the oesophageal region, leading to a diagnosis of Mallory-Weiss Syndrome (MWS). The patient was treated with antibiotics, antipyretics, antiemetics, and antacids. Subsequently, The patient was symptomatically improved, leading to his discharge from the hospital. Keywords: Mallory Weiss Syndrome (MWS), Hypertension (HTN), Type 2 Diabetes Mellitus (T2DM)

A Case of Trichobezoar in an Adolescent Female

Introduction: Trichobezoar is a condition where hair builds up in the stomach, forming a mass that resembles a ball. Since human hair is resistant to peristalsis and digestion, it eventually builds up in the folds of the stomach. Affected individuals with trichotillomania and tricophagia have a propensity to pull out their own hair and consume it. Nearly all of the cases of the condition are in females. Case presentation: Several days prior to her presentation, a 13-year-old female patient arrived at the emergency room complaining of epigastric pain, frequent vomiting episodes, chronic abdominal discomfort, and weight loss. Upon clinical examination, a 20 X 15 cm epigastric mass that descends to the umbilicus is found. All of the laboratory tests came back clean. Ultrasonography and a simple abdominal x-ray were not specific. In order to demonstrate the presence of a significant filling defect extending to the second part of the duodenum within the stomach, a barium meal was performed. An upper endoscopy was performed for additional confirmation and revealed a large trichobezoar that was gastric-confined. This enormous hairy mass was removed through surgery. The post-operative recovery took place without a hitch and produced satisfactory results. Conclusion: Trichobezoar is an extremely rare condition that may be encountered during surgical practice; a high index of suspicion is required for diagnosis, and endoscopy remains the gold standard method for investigation and diagnosis. The primary treatment method is open surgery. All patients require psychiatric consultation and long-term monitoring

Hyperemesis Gravidarum: Looking Beyond Pregnancy

Hyperemesis gravidarum is defined variably as vomiting being sufficiently severe enough to produce weight loss, dehydration, ketosis, alkalosis from loss of hydrochloric acid and hypokalemia. It is not common for a patient affected with hyperemesis gravidarum to present with idiopathic acute pancreatitis in the same time period. This case pertains to a 22-year-old pregnant woman, admitted to our hospital with complaint of severe and frequent episodes of vomiting and severe epigastric pain at 14 weeks of gestation. After treatment with parenteral fluid and antiemetics, the patient’s condition failed to improve. Further investigations confirmed a diagnosis of idiopathic acute pancreatitis. Patient was managed conservatively. Early and rapid diagnosis and supportive treatment play a vital role in the management of such cases.

Congenital intestinal stenosis and Hirschsprung\u2019s disease: two extremely rare pathologies in a newborn puppy

BackgroundHirschsprung’s disease (HSCR) is a common congenital malformation of the enteric nervous system (ENS). During fetal development, ganglion cells of the ENS are derived from neural crest cells that migrate to the bowel. These cells reside principally in two ganglionated plexus: 1) The myenteric plexus, extending from the esophagus to the anus, and 2) submucous plexus, extending from the duodenum to the anus. In large animal species, there is a third plexus called Henle’s or Schabadasch’s plexus.ENS ganglion cells play a key role in normal gastrointestinal motility, respond to sensory stimuli and regulate blood flow. Both plexus show a high degree of independence from the central nervous system. Alterations in the embryonic development of the ENS can induce multiple pathologies in animal models and humans.Case presentationThe present case was a female the fifth born in a litter of 5 puppies. At about 2–3 weeks of age, she suffered from abdominal distension, pain, and constipation. At approximately 8–10 weeks of age, the puppy started to vomit abundantly, and the regurgitated food appeared undigested. Progressive abdominal distention was observed, with quite visible peristaltic movements and more frequent vomiting episodes. The abdominal radiographs, based on AP and side projections, revealed an enlargement of the abdominal diameter and an increased width in the epigastric region. At 12 weeks of age, exploratory surgery revealed a stenotic segment in the jejunum, followed by a small transition zone and then a significantly reduced diameter. Immunohistochemical examinations were performed using antibodies against calretinin, S-100 protein, CD56, neuron specific enolase (NSE) and synaptophysin, which are the biological markers for diagnosing HSCR.ConclusionA reduced number of ganglion cells (1–3 cells per ganglion) were found. There was no specific staining pattern for many of these; while for others, the pattern was compatible with HSCR. Surgical intervention to remove the stenotic section prolonged the life of the puppy for 13 years. Extremely rare pathologies such as that discussed herein should be studied to understand the pathophysiology and be able to diagnose small species in veterinary medicine in a timely fashion. To our knowledge, this is the first report of congenital intestinal stenosis and Hirschprung’s disease in a newborn puppy.

A severe gastroenteritis outbreak of Salmonella enterica serovar Enteritidis PT8, with PFGE profile XbaI.0024 and MLVA profile 2-9-7-3-2 following a christening reception, Greece, 2016.

In June 2016, a Salmonella enterica serovar Enteritidis outbreak (n = 56) occurred after a christening reception in Central Greece, mainly affecting previously healthy adults; one related death caused media attention. Patients suffered from profuse diarrhoea, fever and frequent vomiting episodes requiring prolonged hospitalisation and sick leave from work, with a 54% hospital admission rate. The majority of cases experienced serious illness within <12 h of attending the party. We investigated the outbreak to identify the source(s) of infection and contributing factors to the disease severity. From the retrospective cohort study, the cheesy penne pasta was the most likely vehicle of infection (relative risk 7·8; 95% confidence interval 3·6-16·8), explaining 79% of the cases. S. enterica ser. Enteritidis isolates were typed as phage-type PT8, pulsed-field gel electrophoresis type XbaI.0024, multiple locus variable-number tandem repeat analysis-type 2-9-7-3-2. The strain did not share the single-nucleotide polymorphism address of the concurrent European S. enterica ser. Enteritidis PT8 outbreak clusters. Following five consecutive years with no documented S. enterica ser. Enteritidis outbreaks in Greece, this outbreak, likely associated with a virulent strain, prompted actions towards the enhancement of the national Salmonella molecular surveillance and control programmes including the intensification of training of food handlers for preventing similar outbreaks in the future. Advanced molecular techniques were useful in distinguishing unrelated outbreak strains.

Functional Vomiting Treated Successfully with Aripiprazole in a Child with Autism Spectrum Disorder

[Author Affiliation]Burak Acikel. 1 Department of Child and Adolescent Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey.Ahmet Yar. 2 Child and Adolescent Psychiatry Clinic, Konya Training and Research Hospital, Konya, Turkey.Sabri Herguner. 1 Department of Child and Adolescent Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey.Address correspondence to: Sabri Herguner, MD, Meram Tip Fakultesi, Cocuk ve Ergen Psikiyatrisi AD, 42090, Konya, Turkey, E-mail: herguners@yahoo.comTo The Editor:Autism spectrum disorder (ASD) is defined by deficits in social communication and interaction, as well as by restricted and repetitive patterns of behaviors and activities. In addition to these core symptoms, children with ASD may present with medical conditions, including gastrointestinal dysfunctions. Several studies showed that children with ASD had higher rates of gastrointestinal problems than typically developing controls, such as constipation, diarrhea, bloating, reflux, and vomiting (Kang et al. 2014).Functional vomiting (FV) is defined as vomiting in the absence of gastrointestinal or central nervous system or metabolic diseases. Several pharmacological agents, such as antipsychotics (e.g., chlorpromazine) (Ozdemir et al. 2014), and antidepressants (e.g., mirtazapine) (Coskun and Alyanak 2011) have been reported to be efficient in management of FV. In this report, we describe a child with ASD who had frequent episodes of vomiting that improved after aripiprazole administration.Case ReportA 6-year-old boy with a diagnosis of ASD was referred to our outpatient clinic because of his disruptive behaviors, including hyperactivity, temper tantrums, and irritability. According to his parents, he had also had frequent vomiting episodes, occurring once or twice every day for the past 3 years. His physical examination and diagnostic tests, including endoscopy, were unremarkable. He was diagnosed as having functional vomiting by his gastroenterologist. Risperidone 0.5 mg was initiated for his disruptive behaviors, and the dose was titrated up to 1 mg/day, but no improvement was observed during a 3 month period. Then it was decided to change risperidone to aripiprazole, and the dose was increased to 5 mg/day for a 1 month period. According to the patient's parents, his hyperactivity and irritability did not improve; however, his vomiting episodes remitted completely. He was on this regime for 6 months, and during this time he did not experience any vomiting episode. Six months later, his parents stopped aripiprazole by themselves, as the boy's disruptive behaviors did not improve significantly. However, his vomiting episodes recurred after cessation of aripiprazole. Subsequently, his parents restarted aripiprazole 1 mg/day, and the patient was free of vomiting for 3 months.DiscussionIn this report, we described a patient with ASD who had frequent vomiting episodes and had a marked and rapid improvement following aripiprazole. …

Remote cerebellar hemorrhage due to ventriculoperitoneal shunt in an infant: a case report

IntroductionCerebellar hemorrhage remote from the operative site is an unpredictable and rare complication in neurosurgery, with reported rates of morbidity and mortality in the literature of 8.4% and 7.8%, respectively. The range of procedures associated with remote cerebellar hemorrhage is diverse and includes both supratentorial and spinal procedures that entail significant cerebral spinal fluid loss or resection of supratentorial content. We present here the first documented case of remote cerebellar hemorrhage after controlled supratentorial cerebral spinal fluid drainage by ventriculoperitoneal shunt, and discuss the proposed pathophysiology and treatment.Case presentationWe present the case of a four-month-old Saudi Arabian male baby who presented with progressive symptoms and signs of congenital hydrocephalus. An uneventful ventriculoperitoneal shunting was performed with our patient recovering smoothly in the immediate postoperative period. On the next day, he had frequent episodes of vomiting and became lethargic. An urgent computed tomography scan of his brain revealed mild ventricular decompression and unexpected cerebellar hemorrhage. The infant was put under close observation, with marked spontaneous improvement over 48 hours and complete resolution of the hemorrhage on a follow-up computed tomography brain scan two weeks later. On regular outpatient visits at one, three and twelve months, he had no neurological deficit.ConclusionRemote cerebellar hemorrhage is a complication that remains enigmatic in terms of both the underlying mechanism and clinical behavior. Our case revealed that the risk factors identified in the literature are not sufficient in predicting patients at risk of developing remote cerebellar hemorrhage. Our report also adds to the growing body of evidence challenging the currently accepted hypothesis explaining the pathomechanism of remote cerebellar hemorrhage. It thereby remains an unpredictable hazard that requires further study and increased awareness, as many cases in the literature are incidental findings.

Tooth wear in patients submitted to bariatric surgery

Bariatric surgery may cause frequent vomiting episodes and gastroesophageal reflux, which promote the contact of gastric acids with the teeth leading to irreversible loss of tooth structure. The aim of this study was to assess prevalence of tooth wear in bariatric patients. One hundred and twenty-five patients were examined at a Public Hospital in São Luis, MA, Brazil, between July and October 2010, being patients who had already been submitted to the bariatric surgery at least 6 months previously (Bariatric group), morbidly obese patients who were on the waiting list for this surgery (Obese group) and patients who were waiting for ambulatory medical care in other sectors (Control group). The patients answered an investigative questionnaire and were clinically examined using the Basic Erosive Wear Examination (BEWE) scoring system, which allows the classification of the severity of noncarious dental lesions (NCDL) and evaluation of risk. All patients presented some degree of tooth wear at different levels. However, the presence of NCDL was associated with the group to which the patient belonged. The bariatric patients showed higher prevalence and a statistically significant level of risk with regard to NCDLs when compared with the other patients, followed by the obese and control groups. Reflux and vomiting did not seem to influence NCDL positively.

Cyclic Vomiting Syndrome (CVS): A Management Challenge Across the Ages

Purpose: Case Report: A 17-year-old male presented to the ED with midepigastric pain and recurrent vomiting. He has had multiple prior episodes presenting similarly, occurring 1-2 times per month for the last 6 years. He and his family have a history of migraines, and asthma. He takes ondansetron 4m g and sumatriptan 5 mg as needed. He admits to occasional alcohol and marijuana use. Review of systems is negative except for nausea, repeated episodes of vomiting, and moderate midepigastric pain, present only when he is vomiting. His last bowel movement was one day prior to presentation, and he has had no diarrhea or hematochezia. Physical exam revealed a healthy appearing young male actively vomiting, with midepigastric tenderness and an otherwise nonacute abdomen. Laboratory work up was unremarkable except for bicarbonate of 18, AST 125, and ALT 98. KUB showed normal bowel gas pattern with no evidence of obstruction or ileus. Discussion: CVS is a functional disorder that consists of recurrent paroxysms of nausea and vomiting separated by symptom free periods, with an average of 12 episodes per year. Onset generally occurs before the age of 5. CVS is an under recognized disorder that has no laboratory, radiographic, or endoscopic markers. Acute management focuses on attempting to abort the attack and decrease symptoms while preventing the complications of prolonged vomiting. Sumatriptan can be beneficial initially. Intravenous fluid containing glucose, which limits ketosis, can be effective in terminating attacks. Intravenous ondansetron has been shown to decrease the duration of episodes by more than 50%. Standard antiemetic agents such as prochlorperazine and promethazine are seldom effective, and have the associated risk of extrapyramidal symptoms. Sedation and anxiolysis with agents such as lorazepam is important, as sleep decreases vomiting frequency. Proton pump inhibitors or H2 blockers should also be considered for children with prolonged or frequent episodes of vomiting. Numerous medications are used for prophylaxis, although the quality of evidence to support these agents is limited to anecdotal reports and poorly controlled clinical trials. Antimigraine medications may be effective in those with a family history of migraines. Anticonvulsants, tricyclic antidepressants (TCA'S), carnitine and erythromycin have been reported as effective in limited trials. It is recommended to use a sequential trial of agents starting with the safest agents first (pizotifen, cyproheptadine, propranolol, carnitine), before progressing to TCA's or anticonvulsants. Further management focuses on controlling episode triggers like anxiety, stress, infection, exercise, trauma, menstruation, or other triggers.

Ornithine Transcarbamylase Deficiency Presenting as Recurrent Abdominal Pain in Childhood

Recurrent abdominal pain remains one of the most common symptoms in pediatrics. We present the case of a 3-year-old girl who had recurrent episodes of abdominal pain requiring more than 13 visits to the emergency department. A diagnosis of ornithine transcarbamylase deficiency was eventually made. Urea cycle disorders often present beyond the neonatal period with frequent vomiting episodes; however, recurrent abdominal pain as a presenting symptom is unusual. Unnecessary invasive investigations of recurrent abdominal pain in childhood can be avoided by considering inborn errors of metabolism earlier in the differential diagnosis.

Peripheral polyneuropathy after bariatric surgery for morbid obesity

A patient with peripheral polyneuropathy after bariatric surgery for morbid obesity is reported. She suffered from frequent episodes of vomiting and abdominal pain after surgery. Muscle weakness in her lower limbs developed 5 months later and she experienced difficulty in walking and standing. Wrist drop, foot drop, and marked distal limb muscle atrophy were found bilaterally. Electromyography showed the presence of sensorimotor axonal polyneuropathy. Nutritional deficiencies may play an important role in pathogenesis. This uncommon neurological complication might be due to rapid weight loss and vitamin deficiency. Physicians who take care for patients after bariatric surgery should have a high index of awareness for the neurologic complications, and routine vitamin supplementation might be useful for these patients.

Possible Exacerbation of Crohn's Disease Caused By Varenicline

AbstractPurpose: To report a case of an increase in Crohn's disease (CD) activity possibly caused by varenicline. Background: Smoking cigarettes has been shown to be an independent risk factor for the development of CD and is associated with a more aggressive disease course. Smoking cessation is therefore considered a primary adjunctive goal for such patients. Varenicline is a partial nicotinic agonist, which selectively binds to the α-4, β-2 receptor. This receptor is thought to play a large role in the additive properties of nicotine and the drug is approved in the United States for this purpose. Case results: A 62-year-old female with a 12-year history of stable, quiescent CD, presented to her physician with symptoms of severe nausea, frequent episodes of vomiting, abdominal cramping, and significant diarrhoea, all of which was thought to be her first exacerbation of CD in years. The patient had started varenicline 2 days prior to the initiation of symptoms and had continued worsening symptoms for the next 2 weeks during which she continued the drug. One week after discontinuing varenicline the symptoms abated completely. Due to its pharmacology as a nicotine partial agonist, varenicline was thought to have possibly caused an exacerbation of this patient's CD. Conclusion: A patient had a possible exacerbation of her CD triggered by varenicline used for smoking cessation. Because smoking cessation is imperative in CD patients, care should be used when starting varenicline for this purpose.

Prevention of Postoperative Nausea and Vomiting with Granisetron and Dolasetron in Relation to CYP2D6 Genotype

We investigated the efficacy of granisetron and dolasetron in preventing postoperative nausea and vomiting. Because the metabolism of the various antiemetic 5-hydroxytryptamine type 3 (5-HT3) antagonists involves different isoforms of the hepatic cytochrome P450 system, we examined the relationship between the clinical efficacy of these drugs and polymorphic cytochrome P450 2D6 (CYP2D6) genotype. This prospective, randomized, double-blind study involved 150 adult patients with a moderate to high risk for postoperative nausea and vomiting. All subjects received dexamethasone at induction of anesthesia followed by either 12.5 mg of dolasetron or 1 mg of granisetron. We analyzed the number of complete responders (no vomiting or rescue medication) during the first 24 hours after surgery. CYP2D6 genotyping was performed using a TaqMan real-time polymerase chain reaction. A complete response was more frequent in the granisetron group (54.7%) compared with the dolasetron group (38.7%, P < 0.05). In subjects receiving dolasetron, carriers of the duplication of the CYP2D6 allele predicting ultrarapid metabolizer status had more frequent vomiting episodes (P < 0.05) than patients in the granisetron group. It is postulated that the difference in the antiemetic efficacy between two investigated 5-HT3 receptor antagonists may be associated with differences in the carrier status for the duplication of the CYP2D6 allele.

Effects from pretreatment of stannous fluoride versus sodium fluoride on enamel exposed to 0.1 M or 0.01 M hydrochloric acid

Preventing enamel erosions caused by acidic soft drinks or from vomiting during eating disorders is a challenge in current dental research. The aim of this study was to examine whether pretreatment of dental enamel with a solution of 0.4% SnF2 could prevent dissolution of human enamel exposed to solutions of 0.1 M HCl, pH 1.2 or 0.01 M HCl at pH 2.2. Human enamel was pretreated for 18 h with a solution of 0.4% SnF2 and with control solutions of 2% NaF or distilled water, and then exposed to HCl solutions. Similar experiments were performed with teeth treated for 2 min SnF2 and then 4 min HCl. The effect was monitored by scanning electron microscopy (SEM) and by chemical analysis. At pH 2.2, NaF and water treatments showed minor inhibition of enamel dissolution, whereas SnF[Formula: See Text] inhibited demineralization significantly also after 2 min pretreatment and 4 min HCl exposure. At pH 1.2, SEM showed severe dissolution of the enamel surfaces regardless of pretreatment. As pH of stomach vomit is usually >1.5, SnF2 may be an interesting agent for use in the treatment and prevention of dental erosions even in patients with frequent vomiting episodes.

Idiopathic gastric rupture in a 3‐month‐old girl

This case reports on idiopathic gastric rupture in a 3‐mo‐old girl who had frequent episodes of vomiting and abdominal distension the day before admission to the clinic. Metabolic acidosis was detected and rotavirus antigen was identified in the stools. Abdominal X‐rays and CT scans revealed free air and fluid in the abdominal cavity, leading to a diagnosis of gastrointestinal perforation. During surgery, idiopathic gastric rupture was detected and treated. The postoperative course was uneventful. Conclusion: Idiopathic gastric rupture is extremely rare in childhood beyond the neonatal period. Early diagnosis and surgery are mandatory if children with this condition are to be saved.

Wernicke's syndrome after bariatric surgery

Two young females with severe morbid obesity presented with Wernicke's syndrome after Roux-en-Y gastro-jejunum bypass had been performed. The first patient had recurrent vomiting and dyplopia two months post-surgery. Physical examination indicated bilateral ophthalmoparesia with conserved convergence and ataxia. The second patient had frequent vomiting episodes over the previous three months together with lower limb hypotonia, myoclonia and generalised tonicoclonic seizures on two occasions within one year of surgery. In both cases routine blood test, ion levels (sodium, potassium, calcium, phosphates), electroencephalogram and CT scan were normal. Thiamine therapy was instigated on the basis of clinical intuition and the first patient achieved complete remission within 24 hours while the second improved gradually in that two years later only mild lower limb hypotonia and a slight cognitive deficit remains. Erythrocyte transketolase activity determinations were abnormal on two separate occasions for this second patient. Vitamin B1 determinations were not available for the first patient. In conclusion, the restriction in energy intake and the persistent vomiting together with malabsorption induced by the surgical intervention could explain the vitamin deficiency causing Wernicke's encephalopathy. This indicates a need for close monitoring and systematic vitamin supplementation in those patients who undergo bariatric surgery.

Factors that influence the antiemetic activity of metoclopramide to cisplatin based chemotherapy.

Some clinical parameters play a role in developing effective antiemetic therapy. In the present study, 310 patients entered and 301 were evaluable. They received cisplatin based combination chemotherapy (100 mg/m2), with antiemetic therapy based in metoclopramide, at a standard dose and schedule (2 mg/kg in 5 doses). Patient characteristics such as age, sex, performance status (Karnofsky), site of primary tumor, weight loss >15%, previous chemotherapy, previous radiotherapy, history of vomiting during pregnancy, additional drugs (dexamethasone, alprazolam), in the antiemetic regimen were included in the evaluation. We also studied the manifestation of anxiety and depression and the presence of psychosocial problems related to therapy, evaluated them with specific psychological indexes modified for our study. We evaluated incidence of vomiting, retches, and nausea, with several scales. We distinguished three groups of factors influencing nausea and vomiting. Factors that predicted for increased nausea and vomiting was gender (women), stress and age (younger patients experienced more prolonged duration and higher grades of nausea). The addition of alprazolam (a sedative drug) and dexamethasone, was associated with decreased incidence of nausea and vomiting. The weight loss (increased nausea and decreased vomiting control according to Gralla's scale). Previous chemotherapy decreased the number of patients without nausea and vomiting control according to Gralla's scale. Patients with previous radiotherapy presented an increased grade of nausea. Patients with head and neck cancer presented less nausea with shorter duration, less frequent episodes of vomiting. Patients with ovarian cancer presented increased mean number of retches. In conclusion, despite difficulties in assessing nausea and vomiting among clinical trials, several factors, especially stress, gender, weight loss, additional drugs (corticosteroids and sedatives) may play an important role in modulating the antiemetic response.

A CASE OF ACUTE STENOSIS OF DUODENUM ASSOCIATED WITH TUMOR-FORMING TYPE PANCREATITIS

This paper describes a successfully managed case of acute circular stenosis of the 2nd portion of the duodenum associated with tumor-forming type pancreatitis by medical treatment. A 62-year-old man was emergently admitted to another hospital because of general fatigue, epigastric pain and frequent episodes of vomiting. These symptoms developed one week after recieving upper gastrointestinal series at medical checkup when no abnormality was detected. On admission elevations in serum and urine pancreatic enzymes and dehydration were noted, and so medical treatment with total parenteral nutrition was performed. Imaging examination showed a mass of the pancreatic head and circular stenosis of duodenal 2nd portion. The patient was referred to the hospital for a suspicion of pancreatic cancer. The closed examination revealed no malignancy. Tumor makers were in normal ranges. Medical treatment was continued and the clinical couse was carefully observed. The discharge from a gastric tube decreased, the mass of the pancreatic head reduced and the stenosis was improved about 3 weeks after medical treatment. The definite diagnosis of duodenal stenosis due to tumor-forming type of pancreatitis was made.

The treatment of bulimia nervosa following surgery using a stimulus control procedure: A case study

This single case report describes the treatment of a 35-year-old female, who was diagnosed as suffering from severe bulimia nervosa. Of interest were the frequent vomiting episodes which did not exist prior to two surgical operations performed on the client in order to reduce her overall body weight. The treatment, a stimulus control procedure, which spanned 20 sessions, lasted about 24 weeks and was deemed successful after a year follow-up. Of primary importance was the self-management aspect of the treatment program, which emphasized minimum therapist intervention. In addition, there was a complete absence of “cognitive components” deemed necessary by some authors for the long-term treatment success of bulimics. Different factors relating to the success of this treatment program are also reviewed.

Dissolution of Phytobezoar Using Pineapple Juice

To the Editor.— We wish to report the successful dissolution of a phytobezoar using unprocessed pineapple juice which contains the proteolytic enzyme bromelain. Report of a Case.— A 57-year-old woman underwent hemigastrectomy and bilateral truncal vagotomy for a 1-cm lesser-curvature gastric ulcer that had not healed after eight weeks of intensive medical management. Histopathologic study showed an adenocarcinoma limited to the area under the ulcer. One year later she had no evidence of recurrence and sought to lose weight with a low-calorie diet containing increased amounts of fruits and vegetables. Five months later she noted frequent episodes of vomiting and postprandial epigastric distress. An upper gastrointestinal roentgenographic study showed an 8×13-cm bezoar. A diet low in fiber was initiated immediately. Dissolution with papain (Adolph's Meat Tenderizer) was attempted, but excessive burning discomfort made her stop within two days. She then took bromelain in the form of fresh pine-apple juice; she