Subsequent Ulceration Research Articles

Surgical management of Crohn's disease involving the duodenum

The experience with 25 patients who required operation for Crohn's disease involving the duodenum is reviewed. Two distinct patterns of duodenal involvement are apparent. Intrinsic duodenal Crohn's disease has a characteristic clinical presentation that is distinct from the symptoms seen in patients with involvement of other portions of the gastrointestinal tract. Among 70 patients with duodenal Crohn's disease seen over a 30 year period, 22 required surgical intervention at the Lahey Clinic. Although hemorrhage and intractable pain were associated problems in several of these patients, unrelenting duodenal obstruction remained the primary indication for operation. Of patients who underwent operative bypass, 78 percent had a good result with a median follow-up period of 12.3 years. The presence of associated gastric Crohn's disease did not influence long-term results. A third of the patients required reoperation for duodenal disease. Marginal ulceration and recurrent gastroduodenal obstruction have been the primary reasons for reoperation. Although the addition of vagotomy to operative bypass has not helped to protect against subsequent marginal ulceration, the absence of appreciable morbidity associated with vagotomy in our series and the high incidence of marginal ulcers reported with gastroenterostomy in other clinical settings lead us to recommend gastroenterostomy with vagotomy as the procedure of choice for duodenal Crohn's disease. Proceeding with vagotomy in persons who have had previous ileocecal or extensive small bowel resection should not be undertaken without careful consideration. Similar caution should also be used in patients who are already troubled with poorly controlled diarrhea. The duodenum may also be involved by duodenoenteric fistulas which represent a complication of Crohn's disease involving other portions of the gastrointestinal tract. Most frequently this occurs in patients with Crohn's colitis who have no evidence of intrinsic duodenal disease. Management of the internal fistula requires resection of the involved colon and closure of the duodenal defect. Three patients with duodenocolic fistula have been so treated.

Juvenile leg ulceration in beta-thalassemia major and intermedia.

A series of 12 patients with beta-thalassemia who developed juvenile leg ulcers is described. The trophic skin changes and leg ulcers occurred after the age of 15 years. Usually the ulcer occurred after trauma over the predisposed medial aspect of the leg. In four out of seven females, the trophic changes deteriorated during or following pregnancy. The development of trophic changes and subsequent leg ulcers is not related to the severity of the anemia or to the patients' transfusion requirements, but may be related to high fetal hemoglobin concentration. The ulcers are slow to heal and tend to recur. Multiple skin-grafting operations are required in order to achieve satisfactory coverage of the ulcers. Since tissue hypoxia may be the underlying pathophysiology, the use of topical hyperbaric oxygen chamber may be beneficial in the treatment of thalassemic leg ulcers.

Ascorbic Acid in the Treatment of Alkali Burns of the Eye

Severe ocular alkali burns in rabbits result in a decrease in aqueous humor ascorbate levels to one-third normal levels. If this deficiency is reversed by immediate treatment with parenteral or topical ascorbate, there is a significantly decreased incidence of subsequent corneal ulceration and perforation. The morphologic changes in these ulcerating corneas are typical of those noted in scorbutus (scurvy). It is concluded that alkali injury to the ciliary epithelial transport processes or ciliary body vasculature results in localized deficiency of ascorbic acid in the aqueous humor and cornea. The development of corneal ulceration is thought to be based on this deficiency which results in the failure of fibroblasts to produce sufficient collagen for repair. A randomized clinical trial of ascorbic acid in the treatment of human alkali burned eyes is now underway.

Calcinosis in juvenile dermatomyositis

A retrospective study of the radiographs and clinical records of 39 children with dermatomyositis, followed up at a referral centre for a mean period of eight years, revealed calcinosis in 29 children (18 giris, 11 boys). Clinical presentation of calcinosis was unpredictable and variable, ranging from four months to 12 years after onset of disease. Subcutaneous calcilication, often associated with subsequent ulceration of overlying skin, was observed more frequently than calcinosis in intermuscular fascial planes (29:7). Subcutaneous calcinosis was demonstrated most commonly about the knees and elbows and in the fingers and toes. Intermuscular calcinosis affected the fascial planes around the quadriceps, deltoid, biceps, and the gastrocnemius/soleus muscles.

Leishmania tropica and Leishmania mexicana: Cross-immunity in mice

The effect of a previous or concurrent Leishmania tropica major infection on a L. mexicana infection was studied. Mice which were recovering from or had recovered from a L. tropica infection were found to be totally resistant to L. mexicana. Infection of mice already carrying a L. mexicana infection with L. tropica resulted in subsequent ulceration and eventual healing of the lesions caused by both Leishmania species. Mice infected with L. mexicana were found normally to be no more susceptible to L. tropica than untreated mice: Only when L. tropica infections were located in the region of a draining lymph node already serving a L. mexicana infection did lesions of the former parasite persist.

Duodenal hematoma

Abstract Analysis of the fifty-six cases of duodenal hematoma reported since 1966 shows a significant rise in incidence, with uncertainty regarding the most appropriate approaches to therapy. The diagnosis can generally be made by recognizing the “coil spring” sign on upper gastrointestinal series. Thirty-four per cent of the patients reviewed were treated successfully with conservative management. Sixty-two per cent were treated surgically. Fifty-one per cent of the surgical patients were treated by simple evacuation of the hematoma, and 12 per cent of these required reoperation for recurrent obstruction. Forty per cent of the surgical patients were treated by evacuation and gastrojejunostomy, and 21 per cent of these required reoperation for marginal ulceration. A previously unreported case is presented and a new surgical approach utilizing gastroduodenostomy is described, which is believed to offer potentially less risk of subsequent marginal ulceration or recurrent duodenal obstruction.

Duodenal hematoma: Critical analysis of recent treatment technics

Analysis of the fifty-six cases of duodenal hematoma reported since 1966 shows a significant rise in incidence, with uncertainty regarding the most appropriate approaches to therapy. The diagnosis can generally be made by recognizing the “coil spring” sign on upper gastrointestinal series. Thirty-four per cent of the patients reviewed were treated successfully with conservative management. Sixty-two per cent were treated surgically. Fifty-one per cent of the surgical patients were treated by simple evacuation of the hematoma, and 12 per cent of these required reoperation for recurrent obstruction. Forty per cent of the surgical patients were treated by evacuation and gastrojejunostomy, and 21 per cent of these required reoperation for marginal ulceration. A previously unreported case is presented and a new surgical approach utilizing gastroduodenostomy is described, which is believed to offer potentially less risk of subsequent marginal ulceration or recurrent duodenal obstruction.

Gastric mucosal ischemia in experimental stress ulcer

The pathogenesis of gastric ulceration that occasionally follows major blood loss remains unclear. Localized gastric ischemia is one of several classic explanations [9]. Gastroscopic evidence that focal gastric mucosal ischemia may precede stress ulceration has recently been reported [7]. Visible ischemia has not been correlated with measurements of local mucosal blood flow clinically or in the laboratory. This is a quantitative study of the patterns of blood flow in the stomach of a reliable, experimental stress ulcer model [lo]. Using isotopically labeled microspheres we demonstrated patches of disproportionate mucosal ischemia at sites of subsequent ulceration.

Benign mucous membrane pemphigoid: Management of an edentulous patient

The use of intralesional injections of triamcinolone acetonide in an edentulous patient produced healing of the oral lesions of benign mucous membrane pemphigoid and allowed the prosthodontist to construct new dentures, thus minimizing further trauma to the oral tissues. The method described will not prevent recurrence of oral ulceration in this condition, but any subsequent severe ulceration can be similarly controlled.

Further observations on late radiation necrosis following therapy of skin cancer. The results of fractionation of the total dose.

Previously, one of us 1 reported detailed observations made during a study of 55 instances of late radiation necrosis occurring among 935 cases of basal- and squamous-cell cancer of the skin which had received roentgen therapy between 1946 and 1953. The clinical characteristics more fully described in the earlier report were essentially those of erythema, extreme tenderness, and subsequent necrosis and ulceration occurring in a previously intact irradiation scar, anywhere from several months to six years after completion of roentgen therapy. In that series, four treatment schedules had been employed, but in only two of them were the figures suitable for statistical analysis. These schedules are indicated in Table 1. The probability of developing necrosis during each time interval following therapy in patients who had received treatment Scheme A was presented in the earlier paper in tabular and graphic form as calculated by the standard life table technique. Because of

Subtotal gastrectomy with and without vagotomy for duodenal and gastrojejunal ulcer; present status.

• Subtotal gastrectomy alone was done in 224 patients and combined with infradiaphragmatic vagotomy in 217 patients who had duodenal and gastrojejunal ulcer. Of the three operative deaths, two were in the latter group but could not be ascribed to the vagotomy. Of the 17 proved instances of recurrent peptic ulcer disease, only one was in the vagotomized group. Vagotomy entailed an increase in postoperative morbidity and a risk of prolonged moderate diarrhea, but it afforded some protection against subsequent jejunal ulceration. Gastroenterostomy was done in 101 patients, with vagotomy in 70 of these. The rate of recurrences was 15 % in the patients without and 10 % in the patients with the vagotomy. It appeared that vagotomy afforded little protection to the patients with gastroenterostomy. A continuation of the subtotal gastrectomy of the Billroth 2 type, preferably combined with vagotomy, is recommended on the basis of this experience.

Chronic stress and peptic ulcer. I. Effect of corticotropin (ACTH) and cortisone on gastric secretion.

Since the advent of corticotropin (ACTH) therapy, a number of reports have appeared describing massive gastric hemorrhage or the development, reactivation, or perforation of peptic ulcers during prolonged corticotropin administration. The purpose of this communication is to present evidence that the chronic administration of corticotropin produces an increase in gastric acidity and gastric pepsin with subsequent peptic ulceration, perforation, or hemorrhage. The studies to be presented indicate, moreover, that chronic stress affects the stomach by a hormonal mechanism which is mediated through the adrenal gland. It is well established that chronic physical and emotional stress leads to the release of corticotropin by the pituitary and that corticotropin in turn stimulates the adrenal cortex to secrete a variety of steroid hormones including cortisone and closely related compounds.1The repeated administration of corticotropin over a period of time simulates chronic stress, since it elicits many of the same responses as those

VITAMIN P IN RHEUMATIC EPISTAXIS

NONTRAUMATIC, nonirritant nosebleed is an early manifestation of rheumatic fever, especially in the presence of active heart disease. It may herald the onset of an acute attack, forewarn of an exacerbation of rheumatic activity or develop in a patient convalescing from active carditis. A single severe attack usually gives way to repeated episodes, increasing in frequency and severity with age and rheumatic activity. Bleeding usually arises from Little's or Kiesselbach's area, situated in the highly vascular anterior portion of the nasal septum, although other sites may be affected. Most of the rheumatic children either showed partial organization of the clot, with subsequent ulceration of the nasal septum, or, more often, a visual source of bleeding. Repeated hemorrhages may be so severe and the concern so great that cauterization and transfusion become necessary. Hemorrhagic phenomena accompany rheumatic fever during periods of activity. There may be repeated epistaxis, easy bruising on slight

Spontaneous Renocolic Fistula: Report of a Case

A fistulous communication between the kidney and colon constitutes an exceedingly rare clinical entity, being referred to only casually in the average textbook of urology. Despite the fact that Hippocrates first made mention of this condition, Mertz (1), in 1931, succeeded in collecting only 26 cases over the intervening centuries. Since the excellent clinical and anatomical review of the subject by Vermooten and McKeown (2), 12 additional cases have appeared in the literature. The most recent, and by far the most unique, recorded by Markowitz and Katz (3), was a fistulous connection between the lower pole of a double kidney and the colon. Careful analysis of the literature does not tend to indicate an increased frequency of occurrence, but rather an earlier recognition of chronic kidney disease by improved diagnostic procedures and proper surgical management. The first thorough investigation of renocolic fistula was done by Rayer (4), who believed that a chronic infection of the kidney produced the initial lesion, the adjacent colon becoming attached by fibrous adhesions with subsequent ulceration and fistula formation. To date, no instance of the condition has been reported as a result of a primary bowel lesion. The investigations of Wesson (5), Ratliff and Barnes (6), and Higgins and Hicken (7), show fistula formation to be incident to a chronic suppurative process of the kidney with an associated perinephritis or perinephric abscess. Ratliff also points out that tuberculosis was the least frequently encountered causative agent, occurring only five times in 37 cases reviewed, while renal calculi accounted for 14 cases and 18 were collectively listed as of inflammatory origin. The outstanding symptoms of renocolic fistula are chills and fever, renal colic, and tumor in the flank, which disappears with dramatic suddenness following perforation and evacuation of pus into the bowel. Except in a few of the early cases which were discovered at necropsy, the diagnosis has been made by urographic methods. Hirsch and Bass (8) are of the opinion that the lesion may go undiagnosed unless retrograde studies are made. Wesson (5) and Feldman (9) have each diagnosed a case with the aid of a barium enema. Case History A 42-year-old Austrian-born housewife was admitted to the hospital because of intermittent pain in the chest. Approximately nine months prior to admission, without preceding injury, she experienced a dull aching pain in the lower left chest, which was not aggravated by deep breathing. She denied cough, hemoptysis, or dyspnea, but gave a history of associated high fever with chills and night sweats. A local physician treated her for “pleurisy,” and the symptoms gradually subsided. A month later, the pain recurred, but in a more disabling manner, and failed to respond to the therapeutic measures previously administered. One evening a diarrhea developed, which was followed by marked weakness and the patient fainted.

The Radiological Manifestations in Bilharziasis

Bilharziasis is so widely spread in Egypt that almost 90 per cent. of the population had contracted the disease sometime, either remote or recent. There is no immunity, and the patient can get repeatedly infected. The mode of infection is generally through the abraded skin. No organ in the body is known to be spared from the infection, and bilharzia ova are reported to be found in the heart, lungs, spleen, liver, and gall bladder. In the gall bladder they were not reported to be the cause of cholelithiasis. The systems which sustain the maximum of the disease are the genito-urinary and the intestinal tracts. In the infection of the genito-urinary and intestinal systems the clinical diagnosis of the disease is made easy by the passage of blood in the urine and fæces, where the bilharzia ova can be easily detected microscopically. What interests the radiologist is the consequence of changes arising as a result of the deposition of the bilharzia ova in the submucosa and the subsequent ulceration and the formation of calcareous deposits, which can be revealed radiologically. The X-ray findings in these cases furnish the surgeon with the detail and extent of the lesion. At Kasr-el-Aini Hospital the radiological examination of the urinary tract comprises almost 50 per cent. of the bulk of the routine work, and about thirty patients are examined daily for the manifestations of bilharziasis or for the presence of stones.

The status of surgery for peptic ulcer: Some reflections induced by the 1930 Symposium of the American Surgical Association

1. 1. The symposium conducted at the 1930 meeting of the American Surgical Association on the ultimate results of surgery for peptic ulcers was a valuable piece of work, but does not permit the compilation of the various reports because of the different premises on which they are based. 2. 2. The medical treatment of peptic ulcers has a definite field, but the results are not permanent in the majority of cases; dietary and other restrictions must be rigorously observed; there is an inescapable element of risk; and the correction of coincident intra-abdominal lesions is not possible by it. 3. 3. Surgical treatment must show, to justify its added risk, end-results at least as good as those of medicine, if not better ones. 4. 4. It is illogical to group gastric and duodenal ulcers into one surgical classification, for their pathology and life history demand their individual consideration. 5. 5. Gastroenterostomy gives excellent results for duodenal ulcer and only slightly less good results for gastric ulcer. It is abused and it has its percentage of failures, but these facts are no warrant for the routine performance of the difficult and dangerous operation of gastrectomy for all peptic ulcers. 6. 6. Gastrectomy, even in the most skilful hands, has a higher mortality than gastroenterostomy, and an equal percentage of subsequent marginal ulcers. 7. 7. The solution of the problem lies in the application to every case of good faith, good judgment, conscientiousness and the Golden Rule. We have no moral right to submit our patients to risks we would not choose to incur for ourselves.

DERMATITIS GANGRENOSA INFANTUM

Dermatitis gangrenosa infantum is a rare eruption of gangrenous lesions which supervene on varicella and possibly on other pustular eruptions in children. These lesions usually occur spontaneously and are more common in girls. They appear in groups on the lower parts of the legs, buttocks, thighs and pubic region. If the disease complicates varicella, the distribution of the lesions is the same as that of varicella. The individual lesion appears as a pustule on an inflammatory base. Soon the center of the lesion becomes depressed, and a gray or black crust forms, involving the entire area. At an early stage of the disease, the lesions may become confluent, forming one mass of slough with subsequent ulceration. Various degrees of intensity are seen, from that of the mild, superficial ulceration to the deep, crateriform ulceration which involves the connective tissue. The disease may have its inception as a bullous, pustular or

The Influence of Certain Limited Diets Upon Tumor Susceptibility and Growth in Albino Rats and Mice

It is only within comparatively recent years that the influence of diet upon the growth of tumors in experimental animals has been systematically studied (1–16). Some of these experiments have indicated the existence of a subtle relation between certain dietary deficiencies and neoplastic growth. Some attempts have been made to utilize this method of dietetic treatment in human subjects suffering from malignant diseases, but with essentially negative results. Thus we have tested a diet containing bananas, cooked oatmeal and sugar (a diet deficient in water-soluble Vitamin B) (15) in persons affected with cancer, but found that the treatment was not successful because of the impossibility of starving the tumor without starving the host, which is the usual outcome of experiments along this line. A study made by Wyard (17) showed that the growth of human malignant neoplasms and their subsequent ulceration and the occurrence of cachexia were not affected by feeding patients with Solac, a diet free from fat-soluble Vitamin A. The data were compiled from 64 patients who underwent dietetic treatment for periods from less than a month to 12 months. Copeman (18) and Bulkley (19) have claimed favorable results in the dietetic treatment of human cancer patients. Gibson (20) and Kellogg (21) have discussed the relation of diet to cancer. There is current an idea that the ingestion of an excess quantity of foods very rich in animal protein favors the development of cancerous growths. Although many papers have been written on this subject and there has been much discussion, no definite experimental evidence has been presented (22–38) in this connection. For this reason, investigations upon the influence of natural foods very rich in protein or very poor in protein, and of a diet entirely devoid of protein but containing a large amount of carbohydrate and fat, have been carried out and are reported in the present paper.

ST. THOMAS'S HOSPITAL.: Lacerated Wound of the Thigh and Leg; Subsequent Ulceration of the Popliteal Artery; Hæmorrhage; Transfusion; Deligation of the Femoral Artery; Amputation; Second Transfusion. Death. Autopsy. (Under the care of Mr. SIMON.)

ST. THOMAS'S HOSPITAL.: Lacerated Wound of the Thigh and Leg; Subsequent Ulceration of the Popliteal Artery; Hæmorrhage; Transfusion; Deligation of the Femoral Artery; Amputation; Second Transfusion. Death. Autopsy. (Under the care of Mr. SIMON.)