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In a three-way crossover study, 23 patients with hepatic cirrhosis, ascites, and dependent edema received 40 mg/day of furosemide alone and combined with triamterene 50 mg/day and triamterine 100 mg/day. Baseline potassium excretion did not increase when furosemide was given alone, but potassium excretion fell when 50 mg or 100 mg of triamterene was also given. Both doses of triamterene augmented the natriuretic effect of furosemide.

The mean +/- S.E.M. ratio of amylase to creatinine clearance significantly increased at 24 hours after operations on the stomach and gallbladder but not after operations at sites remote from the abdominal cavity. Clinically, the elevated amylase to creatinine clearance ratio was not accompanied by pancreatitis. In dogs, surgical handling of the pancreas alone caused a significant increase in this measurement. The amylase to creatinine clearance ratio is not likely to be helpful in predicting the rare, but serious, postoperative complication of pancreatitis.

In 31 patients with pancreatitis, the amylase to creatinine clearance ratio (CACR) was significantly greater than for controls (10.7 +/- 1.7 vs. 2.6 +/- 0.3, P less than .001). Sixteen pancreatitis patients with serum amylase (SAm) within the normal range had a mean CACR significantly greater than that of 19 hospital control patients with normal SAm (9.2 +/- 1.5 vs. 3.0 +/- 0.4, P less than .001). For control patients a highly significant inverse correlation between SAm and CACR was observed. No relationship was detected between these parameters for pancreatitis patients. The results suggest that the CACR may be of aid in establishing the diagnosis of pancreatitis even in patients without hyperamylasemia.

We report the unusual concatenation of cecal carcinoma complicated by bacteremia and purulent pericarditis. The organism responsible for the pericarditis was not definitely established. The pericarditis was successfully managed by surgical drainage and antibiotic therapy. Colonic surgery followed eradication of the pericarditis.

Percutaneous transhepatic cholangiography (PTC) with a "skinny" Chiba needle identified the biliary tree in 30 of 31 patients (97%) with extrahepatic obstructive cholestasis (EHC). The method was successful in only eight of 18 patients who had cirrhosis with unexplained jaundice. The biliary tree was visualized after one or two attempts in 23 of 31 patients with EHC (74%). The success rate was significantly greater (p greater than 0.001) in those patients with EHC than in those with EHC, in whom the biliary tree was visualized in 9 of 27 (33%). Difficulties in correctly interpreting the PTC findings in four patients are described.

A prospective randomized matched pair study was designed to test the efficacy of the peritoneovenous (LeVeen) shunt as a treatment for massive cirrhotic ascites compared with traditional medical therapy. Patients who failed to lose weight while on a low salt diet and fluids restricted to 1000 ml daily were placed in the study group. Weight loss, decrease in abdominal girth and diuresis were significantly greater (P less than 0.01) for surgical patients than for their medically treated counterparts. The surgical technique is simple, quick and inexpensive. The surgical patients outlived their matched partners in 12 of 14 pairs where a definitive comparison was possible (P less than 0.02). The median stay in hospital after randomization was shortened from 32 days with medical therapy to 15 days for those undergoing the shunt operation. Those treated medically experienced a significant rise in mean blood urea nitrogen and K+ (P less than 0.02). Patients with alcoholic hepatitis, hyperbilirubinaemia (bilirubin greater than 154 mumol/l), peritoneal sepsis, severe coagulopathy and those who had recently bled from oesophageal varices are poor risks for the surgical procedure.

A 62-year-old man had symptons of congestive heart failure precipitated by chronic blood-loss anemia. Barium-enema studies were consistent with diffuse polyposis of the colon. A total colectomy followed by ileoproctostomy was performed. Histologic examination of numerous polyps showed them to represent villous adenomas. Despite diffuse involvement, electrolyte depletion did not occur. Follow up is planned because of the possibility of future villous adenomas in the small bowel.

Histologic and ultrastructural examination of specimens of rectal mucosa from 11 patients who had recently consumed excessive quantities of alcohol revealed marked pathologic changes. Goblet cells were decreased and a dense mononuclear cell infiltrate was seen on light microscopic study. Electron microscopy revealed swollen, distorted mitochondria and dilated and vesicular endoplasmic reticulum. These abnormalities disappeared after two weeks' abstinence. It is suggested that disordered organelle structure and function might contribute to the diarrhea frequently observed following excessive alcohol intake.

A cirrhotic male patient was admitted with a skin eruption. He had been taking spironolactone and hydrochlorothiazide for two months prior to admission. The morphology and distribution of skin lesions resembled that of systemic lupus erythematosus (SLE). Histologic changes in the skin biopsy specimen were consistent with SLE. Biopsy specimens of normal and affected skin were reported to show weak focal deposition of IgM and complement at the dermal-epidermal junction. However, there was a striking absence of serologic evidence of SLE. The rash disappeared when all medications were discontinued and reappeared when the patient was given spironolactone. The character and distribution of the rash after spironolactone administration was identical to the previous lesions. It disappeared again when spironolactone was withdrawn. This response to spironolactone is good evidence that it and not chlorothiazide was responsible for the rash. The latter drug has been reported to cause SLE-like skin changes.

The case of a patient who had an unsuspected perforated adenocarcinoma of the appendix discovered during operation for a sigmoid carcinoma is presented. The problems in diagnosing carcinoma of the appendix are discussed and the literature is reviewed.

A case of Gardner's syndrome in association with villous adenoma of the jejunum is presented. The discussion stresses that the presence of small intestinal neoplasia in Gardner's syndrome, especially of duodenal sweep and pancreas, is not an infrequent occurrence. Life-long follow-up after total colectomy is indicated for these patients.

The clinical, biochemical and radiological findings in 16 patients with carcinoma of the head of the pancreas were compared with that of 13 with cholestatic jaundice due to chronic pancreatitis. Patients presenting with malignancy had more severe hyperbilirubinemia (18.5 +/- 2.1 vs 5.6 +/- 1.6 p to ten days of hospital admission was the single most accurate test distinguishing carcinoma from pancreatitis. The mean bilirubin rose in carcinoma but fell in pancreatitis (mean net change 15.1 +/- 2.9 vs 3.9 +/- 0.6, p less than 0.001). Calcification in the pancreatic region was identified on a flat plate of the abdomen in 8/13 with pancreatitis but 0/16 with malignancy. Preoperative percutaneous transhepatic cholangiography was helpful in defining the site of biliary obstruction but the radiologist was unable to clearly predict the definitive diagnosis in five of the 29 patients. A point score based upon the major significant differences noted, predicted the presence or absence of malignancy in all patients (16/16 vs 0/13, p less than 0.01).

A patient with a history of alcohol abuse, who presented with severe malnutrition, was subjected to serial jejunal biopsies during his hospitalization. The improvement in villous size and absorptive cell ultrastructure paralleled his clinical recovery. It is concluded that the caloric and trophic benefits of food, the pancreatic and vitamin replacement therapy and withdrawal of alcohol, all played an integral part in the regeneration of the jujunal mucosa.

Hepatomegaly and abnormal liver function can occur in nonmetastatic malignancies. A patient with metastatic prostatic adenocarcinoma that had spared the liver and extrahepatic biliary tree is described. He had puzzling episodes of jaundice for a period of 2 1/2 years. The results of appropriate investigations and an exploratory laparotomy performed dlring the patient's four antemortem hospitalizations were indicative of "recurrent intrahepatic cholestasis," the cause of which remained an enigma even after exploratory laparotomy. At autopsy, no evidence of hepatic metastases or extrahepatic biliary obstruction was found. Alcohol, hepatotoxic drugs, toxins, viral and chronic active hepatitis, hemolysis, and extrahepatic biliary obstruction were eliminated as causes of the jaundice. We believe that the intermittent intrahepatic cholestasis is one of the nonmetastatic manifestations (nonmetastatic hepatopathy of malignancy) of the prostatic adenocarcinoma.

Between 1973 to 1976, 12 ascitic cirrhotic patients with a mean plasma creatinine (pCr) of 4.4 +/- 3.0 mg/dl) were treated conservatively. During the same period 11 cirrhotics with ascites (pCr 4.3 +/- 2.8 mg/dl) were treated with LeVeen peritoneal jugular shunt. In the medically treated group mean survival was 2.4 +/- 2.7 weeks after detection of pCr elevation greater than 2.3 mg/dl. The 11 surgical patients with pCr elevation above 2.3 mg/dl survived a mean of 21.8 +/- 34.5 weeks after surgery. Four patients survived more than six months. The LeVeen shunt also resulted in significant weight loss, reduction in blood urea nitrogen (BUN), elevation of serum sodium, and increase of renal clearance of sodium. In appropriately selected patients it reverses the hepato-renal syndrome.