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Achalasia is an idiopathic neuromuscular disorder of the esophagus which is associated with absence of esophageal peristalsis and incomplete relaxation of a normal or raised lower esophageal sphincter (LES). Dysphagia is the most commonly associated symptom. Conventional therapeutic approaches are directed to reducing LES pressure and include orally-administered smooth muscle relaxants, forceful sphincter dilation with balloon dilators, and open or laparoscopic-assisted myotomy of the LES. Pharmacologic therapies have a low success rate. Forceful dilation has a perforation complication rate of 2% to 5%, and myotomies may precipitate significant gastroesophageal reflux, a complication minimized when a partial fundal wrap is employed simultaneously. In recent years, botulinum toxin, utilized widely as a striated muscle relaxant in managing blepharospasm, anal sphincter spasm, and muscle spasm complicating CVAs, and in smoothening facial wrinkles, has been extended to the management of achalasia on the basis that it impairs smooth muscle responsiveness to acetylcholine. Eighty units of Botox (botulinum toxin) are injected directly into the endoscopically (endoscopic ultrasound techniques may facilitate localization) located LES region (20 units into each of 4 quadrants). Symptom relief lasting 6 months on average is experienced in more than 65% of treated patients, and the complication rate is negligible. This therapeutic option is reserved for patients too ill to undergo any surgical procedure and is most effective when the lower esophageal region is hypertonic.

Advances in achalasia has led to the development of new therapeutic options. This review will focus on methodology and outcomes of two established techniques; pneumatic dilation and surgical myotomy; and one new technique, LES injection of botulinum A toxin.

Collagenous colitis is a relatively recently described well-recognized entity. Considered a unique variety of idiopathic inflammatory bowel disease, it was initially grouped along with lymphocytic colitis and called microscopic colitis. Its distinctive histological characteristics include a thickened subepithelial collagen band, evidence for chronic inflammation in the lamina propria, and increased intraepithelial lymphocytes. Multiple therapeutic approaches have been attempted including mesalamine compounds and corticosteroids with variable responses, usually requiring either maintenance therapy or repeated courses to maintain a state of remission. We describe a case of collagenous colitis treated with a short course of open-label bismuth subsalicylate (PeptoBismol) with prompt resolution of symptoms and histological abnormalities, and a prolonged clinical remission.

Summary Background Intestinal transplantation is used in patients with short-bowel syndrome after repeated resections for Crohn's disease. We report the apparent clinical recurrence of Crohn's disease in a transplanted intestine. Methods and findings The patient, a 33-year-old Hispanic woman, underwent small-bowel transplantation in December, 1994. Immunosuppression with tacrolimus, methylprednisolone, bone-marrow infusions, and OKT3 was given. In July, 1995, the patient had recurrent abdominal symptoms. The histological diagnosis of Crohn's disease was established by the independent interpretations of four experienced gastrointestinal histopathologists. Interpretation The prompt appearance of this autoimmune disorder (within 6 months of transplantation), despite massive immunosuppression may provide important insights into the nature of Crohn's disease and of the recurrence of autoimmune disease during immuno-suppression.

Too often, actions and decisions affecting patient care are determined by expediency, cost-effectiveness, and time constraints. At risk of sacrifice are ethics and professionalism, pillars essential to the very structure of medical practice. In particular, there appears to be an erosion of consultation etiquette-exchanges between physicians and patients as well as among physicians. While methods to maximize efficiency are essential to medical practice, they should not come at the expense of etiquette. To improve patient care and strengthen relationships between patients and physicians, as well as relationships between referring and consulting physicians, a set of guidelines for improving consultation etiquette is proposed.

PreviewTraditionally, sulfasalazine and corticosteroids have been used to treat Crohn's disease. However, therapy has been expanded to include other drugs, and several newer agents show clinical promise. The authors discuss the therapeutic options now available and describe results of several drug trials. Despite the apparent benefits of newer therapies, caution must be used in choosing appropriate treatment.

Dieulafoy's lesion is an uncommon cause of gastrointestinal bleeding that occurs after rupture of an exposed submucosal artery. The vast majority of lesions are found in the stomach, but cases have been described in the esophagus, small intestine, colon, and rectum. We describe an elderly patient who presented with severe lower gastrointestinal bleeding caused by a rectal Dieulafoy's lesion. This is the first report of a rectal Dieulafoy's lesion treated successfully with endoscopic epinephrine injection followed by thermocoagulation. We review the physiopathology, clinical presentation, diagnosis, and treatment of this disease.

Many agents seem to be equally effective for the treatment of peptic ulcer disease. This is true despite the drugs' varied mechanisms of action, and this observation has caused investigators to shift their focus from aggressive to defensive factors when studying ulcer pathogenesis. Patients with a healed ulcer are always at risk for recurrence, and guidelines are available for management of these patients. Ulcer prevention becomes a crucial issue in intensive care units where critically ill patients have many known risk factors. Maintaining a gastric pH above 4.0 appears to reduce the morbidity and mortality associated with such stress-induced ulcers. Use of nonsteroidal anti-inflammatory drugs increases ulcer risk and complications in the elderly, in women with rheumatoid arthritis, and in smokers and abusers of alcohol. Prophylaxis with the synthetic prostaglandin analogue misoprostol (Cytotec) appears to reduce this risk.

Significant advances have occurred in our understanding of the biology, immunology, and immunopathology of the usually asymptomatic human infection by the intestinal parasite, Strongyloides stercoralis. Factors that increase the risk for the occurrence of symptomatic intestinal hyperinfection and/or often-fatal disseminated strongyloidiasis have been better defined. The pathophysiology underlying these risk factors, whether disease-related or iatrogenically induced, is a compromised immune system leading to dysfunction of TH-2 helper cells. These specialized lymphocytes are central to maintaining the delicate balance that exists between the infected human host and the stabilized parasite. Recognition of risk factors that impair the function of TH-2 lymphocytes is essential to heightening the index of clinical suspicion enhancing earlier, accurate diagnosis, and the introduction of appropriate therapy. This review summarizes what is understood about infection by S. stercoralis; its focus will be on the epidemiology, diagnosis, clinical presentation patterns in the immunocompetent and immunocompromised human hosts, and recommended treatment regimens.

Inflammatory bowel disease (IBD) has an impact on the quality of life of women regarding partner relationships and sexual health. Partner relationship and sexual health in women with IBD has been targeted minimally for investigation in the literature devoted to psychological, relationship, and sexual functioning. The purpose of the present article is to describe the concerns of women with IBD, specifically evaluating individual concerns, partner relationships, and sexual functioning after surgery and to elucidate some of the difficulties in identifying such problems. Gynecologic issues and pregnancy concerns are described. Actual case studies are presented that reveal many of the difficulties women with IBD encounter in their relationships as a consequence of disease activity and treatment interventions. Additional research evaluating relationship difficulties, sexual comfort, and sexual behaviors as a consequence of disease activity is required to understand further and improve the quality of life and well-being of these women.

Colonic ischemia is the most common form of intestinal ischemia. It results from reduction in blood flow to the gastrointestinal tract, which, when prolonged, brings a spectrum of gross and microscopic changes in the affected intestinal wall. Clinical presentations range from asymptomatic to acute and fulminant, and outcomes from reversible to chronic and progressive or fulminant, with high morbidity and low mortality. This article presents an overview of colonic ischemia and discusses potential changes in imaging and treatment.

Amyloidosis may uncommonly present with intestinal pseudo-obstruction. Previous reports have described an acute presentation with AA amyloid and a more chronic syndrome with AL amyloid. We report the case of a 78-yr-old man who presented with clinical and radiographic features of an acute small bowel obstruction and who, at laparotomy, was found to have intestinal pseudo-obstruction due to AL amyloidosis. We believe this case represents the first report of acute pseudo-obstruction from AL amyloidosis; awareness of this presentation may facilitate earlier diagnosis.

Gastroparesis, defined as delayed gastric emptying because of abnormal gastric motility in the absence of mechanical outlet obstruction, is a common problem causing significant morbidity. Although many cases are caused by diabetes, more than 90 different conditions are known to interfere with normal gastric motor function (Scand J Gastroenterol 1995;30[suppl]:7-16). Patients may present with nausea, vomiting, heartburn, early satiety, or postprandial pain. The current gold standard for quantifying gastric emptying is nuclear scintigraphy. The main goal of treatment is to improve patient comfort by accelerating the rate of gastric emptying, which may be achieved through dietary changes and the use of prokinetic agents. In rare instances, relief can only be obtained with surgical intervention. This report reviews the pathophysiology, clinical presentation, evaluation, and treatment of patients with gastroparesis, an understanding of which will lead to more effective patient care.

The Sister Mary Joseph's nodule is a significant finding in the physical examination. It is sometimes the only indication of an intra-abdominal metastatic malignancy. We report a patient who presented with an umbilical nodule that was discovered to be an omphalith. A review of the literature discusses the Sister Mary Joseph's nodule and this unusual finding.

Medical care and the practice of medicine as we have known it, and in many ways still wish it to be, is no longer what it once was and unlikely ever to be again. The major consequence of the changes we have experienced is the loss of a degree of control we physicians once possessed. There is less of the passion once felt by many of us who were drawn to the medical profession for mostly the right reasons. External pressures, well known and too numerous to recount at this time, are damaging the cornerstone of medicine, the physician–patient relationship. Physicians are angry, frustrated, and working harder than ever to adapt to changes and pressures and to continue to deliver high-quality medical care despite the obstacles. Patients are angry, frustrated, and working harder than ever to learn how to cope with changing rules and doctors. The cornerstone has been chipped, eroded somewhat, but not destroyed, and is still recognizable easily whenever some circumstance, scheduled or otherwise, brings together the physician and patient no matter the setting. This brief editorial is directed to physicians who still care and will continue to care about the physician–patient relationship.

To turn a well-known phrase regarding history, those who forget to diagnose strongyloidiasis will be condemned to rediscover it. The often protean manifestations of this disease cannot be emphasized enough. The parasite's unique life cycle enables it to live for decades in an unsuspecting host, presenting with symptomatic disease only occasionally. Making a definitive diagnosis may be difficult and requires persistence. A good history should reveal whether a patient belongs to a high-risk group. The physician should strongly suspect the diagnosis when nonspecific cutaneous, pulmonary, and gastrointestinal symptoms coexist. Unexplained enteric bacteremia or meningitis may be important clues to diagnosing disseminated disease, which carries a high mortality rate. Therapy is available, and advances are being made to make it more tolerable. Follow-up for eradication is laborious yet essential: In patients at high risk for disseminated disease, invasive procedures may be warranted to prove eradication. Incomplete therapy puts the patient at further risk for significant complications in the future.

Brand et al. prospectively studied the outcome of endoscopic sphincterotomy in 29 consecutive patients with biliary-type pain (two or more out of eight criteria), elevated liver enzyme levels (AST, ALP, or γ-glutamyltransferase), and no clear evidence of biliary pathology on transabdominal ultrasound and diagnostic endoscopic retrograde cholangiography. Elevated bilirubin levels (range = 1.3–7.2 mg/dl) were found in 18 patients. The majority of patients (n = 21) had gallbladders in situ. The findings from bile duct exploration after sphincterotomy were recorded, and pain (as measured by a visual analogue scale) and laboratory findings were assessed. The inclusion criteria for endoscopic sphincterotomy were 1) the presence of at least two of any eight characteristics associated with typical biliary-related pain (coliclike, located at the right upper abdomen, radiation to back or right shoulder, pain intensity > 4 on the visual analogue scale [possible range = 0–10], duration of pain > 30 min, postprandial pain, symptoms occurring at night, precise definition of onset and relief of pain), 2) elevated liver enzyme levels (AST, ALP, or γ-glutamyltransferase elevated more than 2-fold) in patients without histories of alcohol abuse or liver disease, and 3) absence of clear pathology on diagnostic endoscopic retrograde cholangiography—that is, no or only mild dilation of the biliary duct system (common bile duct ≤ 12 mm in patients who had undergone cholecystectomies, and ≤ 8 mm in patients with gallbladders in situ) as measured in relation to the diameter of the duodenoscope. Wire-guided sphincterotomy was successful in all patients, whereas uncomplicated pancreatitis occurred in one instance. In 16 patients (55%) there was macroscopic evidence of small stones (n = 2), sludge (n = 12), or both (n = 2) after bile duct exploration with a Dormia basket. In addition, microscopy revealed cholesterol crystals in four patients who had no macroscopic findings. All four patients with elevations of pancreatic enzymes before treatment and four of those eight patients with previous cholecystectomies demonstrated evidence of biliary pathology. The initial median pain intensity was 8 (range = 1–10); 26 patients became pain free within 3 months after endoscopic sphincterotomy. Twenty-six of 28 patients (93%) remained asymptomatic over a median follow-up period of 19 months (range = 12–26); one died of an unrelated malignancy 6 months after therapy. The authors concluded that endoscopic sphincterotomy may be acceptable therapy in patients with clinical presentations suggesting papillary or biliary origins of pain without further diagnostic workup.

Brand et al. prospectively studied the outcome of endoscopic sphincterotomy in 29 consecutive patients with biliary-type pain (two or more out of eight criteria), elevated liver enzyme levels (AST, ALP, or γ-glutamyltransferase), and no clear evidence of biliary pathology on transabdominal ultrasound and diagnostic endoscopic retrograde cholangiography. Elevated bilirubin levels (range = 1.3–7.2 mg/dl) were found in 18 patients. The majority of patients (n = 21) had gallbladders in situ. The findings from bile duct exploration after sphincterotomy were recorded, and pain (as measured by a visual analogue scale) and laboratory findings were assessed. The inclusion criteria for endoscopic sphincterotomy were 1) the presence of at least two of any eight characteristics associated with typical biliary-related pain (coliclike, located at the right upper abdomen, radiation to back or right shoulder, pain intensity > 4 on the visual analogue scale [possible range = 0–10], duration of pain > 30 min, postprandial pain, symptoms occurring at night, precise definition of onset and relief of pain), 2) elevated liver enzyme levels (AST, ALP, or γ-glutamyltransferase elevated more than 2-fold) in patients without histories of alcohol abuse or liver disease, and 3) absence of clear pathology on diagnostic endoscopic retrograde cholangiography—that is, no or only mild dilation of the biliary duct system (common bile duct ≤ 12 mm in patients who had undergone cholecystectomies, and ≤ 8 mm in patients with gallbladders in situ) as measured in relation to the diameter of the duodenoscope. Wire-guided sphincterotomy was successful in all patients, whereas uncomplicated pancreatitis occurred in one instance. In 16 patients (55%) there was macroscopic evidence of small stones (n = 2), sludge (n = 12), or both (n = 2) after bile duct exploration with a Dormia basket. In addition, microscopy revealed cholesterol crystals in four patients who had no macroscopic findings. All four patients with elevations of pancreatic enzymes before treatment and four of those eight patients with previous cholecystectomies demonstrated evidence of biliary pathology. The initial median pain intensity was 8 (range = 1–10); 26 patients became pain free within 3 months after endoscopic sphincterotomy. Twenty-six of 28 patients (93%) remained asymptomatic over a median follow-up period of 19 months (range = 12–26); one died of an unrelated malignancy 6 months after therapy. The authors concluded that endoscopic sphincterotomy may be acceptable therapy in patients with clinical presentations suggesting papillary or biliary origins of pain without further diagnostic workup.

This study was designed to assess the efficacy of i.v. infusion of neostigmine in patients with acute colonic pseudo-obstruction, which was defined as colonic distention with a cecal diameter of at least 10 cm on plain radiographs and no radiographic evidence of mechanical obstruction. Patients who failed to respond to conventional management (nothing by mouth, nasogastric suction, postural changes, i.v. fluids, electrolyte replacement, and discontinuation of any drugs that affect colonic motility) for 24 h were included in the study. Those with bradycardia (heart rate 3 mg/dL were excluded. Twenty patients were included in this prospective, randomized, double-blind, placebo-controlled study. Eleven patients received neostigmine 2.0 mg i.v. over 3-5 min with electrocardiographic monitoring, and 10 received placebo. Patients were evaluated for immediate clinical response (passage of flatus or stools associated with decreased abdominal distention within 30 min) and sustained response with decreased abdominal girth and reduced colonic dilation on radiographs 3 h after infusion. Ten patients in the neostigmine group had an immediate clinical response (median time, 4 min) compared to none in the placebo group (p

When a patient has epigastric pain that worsens 1 to 3 hours after meals, the possibility of peptic ulcer disease should be considered. Completely typical clinical presentations in patients younger than age 50 justify empirical therapy when no physical or laboratory findings suggest a mimicking disorder. Esophagogastroduodenoscopy should be undertaken when response to therapy is incomplete, symptoms recur quickly, or dyspeptic symptoms present for the first time in a patient older than age 50. When gastric ulcers are diagnosed radiographically, endoscopy and biopsy at multiple sites should be done to exclude malignant disease. Intractable duodenal ulcers may necessitate endoscopic biopsy of antral and duodenal mucosa to rule out an associated Helicobacter pylori infection, which may modify therapeutic approaches. Zollinger-Ellison syndrome is rare but should be suspected when ulcer disease presents atypically or aggressively or in families. Diagnosis is not difficult to confirm.

Source Citation Camilleri M, Northcutt AR, Kong S, et al. Efficacy and safety of alosetron in women with irritable bowel syndrome: a randomised, placebo-controlled trial. Lancet. 2000 Mar 25;355:10...

(2000) Ann Intern Med 133, 136. Jailwala J, Imperiale TF, Kroenke K. . Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials. . Jul 18; . : . –47. . [OpenUrl][1][PubMed][2][Web of Science][3] QUESTION: What is the effectiveness of pharmacological agents for the treatment of irritable bowel syndrome (IBS)? Studies were identified by searching Medline (1966–99), EMBASE/Excerpta Medica (1980–99), PsycINFO (1967–99), and the Cochrane Controlled Trials Registry with terms that included colonic diseases, functional, irritable, spastic, bowel, and colon and by manually searching bibliographies of relevant studies. Published studies in the English language were selected if they examined use of a pharmacological treatment for IBS on >10 adult patients for ≥2 weeks; included a placebo group; reported an outcome measure of global status or individual symptoms, or both, of IBS; and used a randomised, double blind, parallel group or crossover design. Data were extracted on the diagnostic criteria for IBS, participant characteristics, interventions, study design, methodological quality (scored between 1 and 5 with a higher score representing higher quality; studies with a score ≥4 were classified as “high quality”), and outcomes. Pharmacological agents were classified as having “positive” effectiveness if the study reported significant improvement in global status or individual IBS symptoms; otherwise, they were classified as having “negative” effectiveness. 70 studies (4836 patients, median age … [1]: {openurl}?query=rft.jtitle%253DAnnals%2Bof%2BInternal%2BMedicine%26rft.stitle%253DANN%2BINTERN%2BMED%26rft.issn%253D0003-4819%26rft.aulast%253DJailwala%26rft.auinit1%253DJ.%26rft.volume%253D133%26rft.issue%253D2%26rft.spage%253D136%26rft.epage%253D147%26rft.atitle%253DPharmacologic%2BTreatment%2Bof%2Bthe%2BIrritable%2BBowel%2BSyndrome%253A%2BA%2BSystematic%2BReview%2Bof%2BRandomized%252C%2BControlled%2BTrials%26rft_id%253Dinfo%253Apmid%252F10896640%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10896640&link_type=MED&atom=%2Febmed%2F6%2F1%2F20.atom [3]: /lookup/external-ref?access_num=000088258500007&link_type=ISI

Source Citation Gendre JP, Mary JY, Florent C, et al. Oral mesalamine (Pentasa) as maintenance treatment in Crohn's disease: a multicenter placebo-controlled study. Gastroenterology. 1993 Feb;104:4...

A search for the cause of microcytic hypochromic anemia and occult blood in stool leads to discovery of an adenomatous polyp near the anal verge with carcinoma in situ in the epithelial mucosa. The additional finding of a narrowed colonic segment requires differentiation of various possible causes.

Gastric secretion was evaluated in 9 male patients with chronic renal failure on maintenance hemodialysis. Five secreted low or normal quantities of acid and 4 exhibited hypersecretion, 2 of whom had associated peptic ulcer disease. Serum gastrin responses to a protein meal were comparable to control subjects. Calcium infusion in two basal hypersecretors depressed acid secretion. The only statistically significant correlation observed was between basal acid output ans serum levels of parathormone. These studies suggest that while acid secretory abnormalities vary in patients with chronic renal failure on hemodialysis, there is no apparent sensitivity of the gastrin-secreting cells to protein or calcium ion which might account for acid hypersecretion. Secondary hyperparathyroidism may influence the occurrence of acid secretory abnormalities.

With stasis of intestinal contents or direct contamination by a fistula connecting the upper bowel to the lower, the proximal small bowel becomes the site of bacterial overgrowth. All the clinical features of the blind loop syndrome can be related to this bacterial proliferation in a part of the bowel where underpopulation by bacteria is the rule.

Gastrointestinal disorders are associated with severe and often complex acid-base disturbances. We review the most important types of metabolic alkalosis and metabolic acidosis associated with gastrointestinal disorders, excluding liver disease. Special emphasis is placed on pathophysiologic mechanisms. This information may help the clinician understand the generation and maintenance of these disorders and to plan an effective therapeutic approach.

Answers to the questions posed here should enable the physician to determine whether a patient's dysphagia is caused by motor or structural disorder and where the obstruction or dysfunction is located.

A middle-aged man with a history of duodenal ulcer comes to the emergency room because of symptoms that indicate obstruction of the gastric outlet. An alert physician orders a serum gastrin test. The value is reported as 450 pg/ml. What steps would you take to find the cause of the high gastrin value?

When ascites is the presenting symptom and the underlying disease is not apparent, the physician must be aware of the various diseases that may be associated with the accumulation of serous fluid in the abdominal cavity and the various approaches that are available to aid in the differential diagnosis.

The pre-operative diagnosis of a pancreatic abscess was not considered in a comprehensive review in 1972. However, advances in technology (Ultrasound-US, Computed Tomography-CT) has allowed guided percutaneous needle aspiration (PNA) of suspected pancreatic lesions. The purpose of this study was to evaluate the safety and diagnostic ability of PNA to differentiate acute pancreatic inflammatory masses from pancreatic abscess (PA). Thirteen patients underwent PNA after US or CT revealed an acute pancreatic inflammatory mass (12/13 cystic). One patient underwent a second aspiration. Clinical features T°-101.3°F mean (13/13), leukocytosis 14,400 cu/mm (11/13). Aspirated material was gram-stained and examined for bacteria and leukocytes and cultured. Results: PNA was accomplished successfully in all patients. Aspirate revealed bacteria in nine and pancreatic abscess was confirmed at surgery (8) or post-mortem exam (1). Four of five patients in whom no bacteria were visualized had medical resolution, the fifth had continued T° and underwent a second aspiration which diagnosed a PA. PA contained moderate to large number of PML via aspiration. Conclusions: PNA provides a potentially important and safe diagnostic adjunct to earlier accurate differential diagnosis of pancreatic inflammatory masses from pancreatic abscess.

Gastroduodenal Crohn's disease usually, but not always, occurs in patients with previously established ileal and/or colonic Crohn's disease. Symptoms include postprandial epigastric pain accompanied by nausea and sometimes vomiting, weight loss, anorexia, bloating, and diarrhea. Obstruction is the most common complication. Diagnosis can usually be made radiographically or endoscopically. Certain radiographic patterns are almost diagnostic, eg, obliteration of a distinct pyloric channel and a rigidly narrowed antrum tapering into a diseased duodenal bulb. Endoscopic mucosal biopsy of abnormal areas almost always shows chronic inflammation, although granulomas are not common. In patients with symptoms other than intractable obstruction, medical management, such as intermittent corticosteroid therapy, should be attempted. Surgery is usually indicated for refractory obstruction; gastrojejunostomy is the preferred approach.

This is the first reported case of a single gastrointestinal malignancy in an adult in which both alpha-fetoprotein and carcinoembryonic antigen were detected in similar tumor tissue. Hepatic metastases from gastric adenocarcinoma were found to contain both AFP and CEA. The primary tumor contained only carcinoembryonic antigen. Alpha-fetoprotein may represent antigen produced locally by hepatic tissue in response to the presence of tumor; its function is speculative.

Summary A case of agenesis of the gall bladder and cystic duct with associated choledocholithiasis and suppurative cholangitis has been presented. Incidence of the congenital disorder, its symptomatology and associated pathology have been reviewed. Mechanisms responsible for common duct dilatation in the absence of calculi as well as for the formation of calculi in the absence of the gall bladder are discussed. A rational therapeutic approach is outlined.

Twenty-two years after surgery for recurrent bleeding duodenal ulcer, a 63-year-old man was found to have an unresectable tumor just proximal to the gastrojejunal anastomosis. The incidence of carcinoma in the gastric remnant in patients who have had such surgery is significantly higher than in the general population. The mean time between surgery and diagnosis of carcinoma is 22 years. In patients who have undergone surgery for benign ulcer disease, new or altered symptoms appearing ten or more years after gastric surgery call for a high level of suspicion combined with in-depth investigation. Prompt, accurate diagnosis may result in improved survival.

A case report and review of the literature of benign gastric ulcer complicated by gastrocolic fistula are presented. Twenty-seven percent of patients were found to be receiving ulcerogenic medications. Only 15% of patients had previous histories of ulcer disease. Parameters most suggestive of a neoplastic process included palpable abdominal mass and unexplained anemia. Diagnosis is established by barium enema. Endoscopic biopsy and cytologic studies are useful in differentiating benign from malignant processes. Surgical management of benign ulcers complicated by fistula results in more than 90% survival.

Two patients developed local gangrene after subcutaneous infiltration of vasopressin (Pitressin, Parke, Davis & Company, Detroit, Mich.) utilized for the control of bleeding from esophageal varices. In the 1st patient, ischemic gangrene resulted in transmetatarsal amputation and also necessitated skin grafts on the forearm. The 2nd patient developed gangrene and clostridial sepsis and expired. The effects of systemically administered Pitressin are reviewed and suggestions to prevent local necrosis are presented.