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A 42-year-old Hispanic female was referred for investigation of unexplained weight loss. Initial upper endoscopy showed atrophic gastritis. Repeat endoscopy one year later revealed the presence of mixed composite tumor consisting of gastric adenocarcinoma and carcinoid tumors. Treatment was accomplished by surgical excision. Such cases are extremely rare and few such reports are available in the literature. We discuss the pathologies and means by which these tumors are classified and treated.

In this article, disease of the small intestine will be discussed, with particular reference to those conditions leading to malabsorption and malnutrition. The work up of these entities will be emphasized, with focus on bacterial overgrowth, celiac sprue and nonsteroidal-induced enteropathy.

The current study reviews the Bridgeport Hospital experience with gallstone pancreatitis (GP) and examines its incidence by race and gender.Consecutive patients admitted with acute pancreatitis between October 1994 and October 1996 were identified using discharge diagnosis codes. Demographics and clinical information were abstracted. Patients were categorized as having definite GP, probable GP, and non-GP using the available information.One hundred twenty-three patients met criteria for acute pancreatitis. Of these, 40 met the criteria for definite GP; 14, probable; and 69, non-GP. The estimated incidence for acute pancreatitis was 45 per 100,000 person-years (95% CI = 41-58 per 100,000 person-years) for definite GP and was 20 per 100,000 person-years (95% CI = 14-25 per 100,000 person-years) for probably GP. Patients with definite or probable GP were predominantly white or Hispanic women and tended to be older. Only 16% of pancreatitis in black patients was associated with gallstones. Elevated alanine aminotransferase (ALT120 U/L) was highly specific (97%) in predicting GP, with a positive likelihood ratio of 18.3. Abdominal ultrasound was the most widely used imaging study. Complication rates were low. There was only one intrahospital death.The incidence of acute pancreatitis requiring hospitalization at our community hospital in 1994-1996 was 45 (95% CI = 41-58) per 100,000 person-years. Forty percent of these cases were associated with gallstones. Gallstone pancreatitis was more common among the elderly women and the white (white, non-Hispanic) population. Elevated ALT was highly specific in the prediction of GP.

Small bowel diseases in the elderly are discussed including small bowel gastrointestinal bleeding and malabsorption syndromes such as celiac disease. Crohn's disease and nonsteroidal enteropathy also cause considerable morbidity in the elderly population and are reviewed. Finally, a brief discussion of malignancies of the small bowel (adenocarcinoma, carcinoid, and so forth) occurring in the elderly is presented.

Introduction Saw palmetto is a phytotherapeutic agent commercially marketed for the treatment of benign prostatic hyperplasia. Evidence suggests that saw palmetto is a safe product, and mild gastrointestinal adverse effects have been reported with its use. We report a case of acute pancreatitis, possibly secondary to the use of saw palmetto. Case presentation A 61-year-old Caucasian man with a history of benign prostatic hyperplasia and gastroesophageal reflux disease developed epigastric pain associated with nausea 36 hours prior to presentation. He denied drinking alcohol prior to the development of his symptoms. His home medications included saw palmetto, lansoprazole and multivitamins. Laboratory results revealed elevated lipase and amylase levels. An abdominal ultrasound demonstrated a nondilated common bile duct, without choledocholithiasis. Computed tomography of his abdomen showed the pancreatic tail with peripancreatic inflammatory changes, consistent with acute pancreatitis. Our patient's condition improved with intravenous fluids and pain management. On the fourth day of hospitalization his pancreatic enzymes were within normal limits: he was discharged home and advised to avoid taking saw palmetto. Conclusion It is our opinion that a relationship between saw palmetto and the onset of acute pancreatitis is plausible, and prescribers and users of saw palmetto should be alert to the possibility of such adverse reactions.

Catheter-associated urinary tract infection (CA-UTI) is the most common health care-associated infection. Instrumentation of the urinary tract, mainly urinary catheterization, is the most important risk factor for CA-UTI. It is believed that proper catheter management can reduce the incidence of CA-UTI.This was a prospective preintervention and postintervention study conducted to assess the effect of an intervention aimed at preventing CA-UTI. A reminder sticker was placed on each patient's medical record binder to remind the physicians to consider discontinuing any unnecessary urinary catheters.There was a statistically significant increase in the number of appropriately retained urinary catheters at 3 months (57% vs 73%; P = .007) and 6 months postintervention (57% vs 86%; P.001). There was also a statistically significant reduction in the rate of CA-UTI after 3 months (7.02 vs 2.08; P.001) and 6 months postintervention (7.02 vs 2.72; P.001).A simple intervention using a sticker placed on patients' medical record binder to remind physicians to remove unnecessary urinary catheters can significantly increase the appropriate utilization of urinary catheters and decrease the rate of CA-UTI in community teaching hospitals.

Introduction Bordetella bronchiseptica can be a cause of virulent pneumonia in humans with impaired immune systems. Few cases have been reported in the medical literature where Bordetella bronchiseptica has been the only pathogen isolated during a course of interstitial pneumonia. Case presentation A 42-year-old African-American man with human immunodeficiency virus presented with pulmonary symptoms that mimicked Pneumocystis jiroveci pneumonia. A sputum culture grew Bordetella brochiseptica, a common respiratory commensal of wild and domestic animals, rarely implicated in human infections. Conclusion Bordetella bronchiseptica should be added to the differential list of pathogens which can affect people with human immunodeficiency virus and pulmonary symptoms. Sputum culture, as well as history of animal exposure, in these patients is advised.

SUMMARY Diseases of the pancreas in children are often congenital; the genetic basis of some conditions such as cystic fibrosis have been elucidated using molecular biologic techniques. Anatomic abnormalities in childhood that cause symptomatic pancreatic disease are usually treated surgically. The biochemical abnormalities found with enzyme deficiencies, CF, and Shwachman's syndrome are best treated with medical therapy. The most common cause of acute pancreatic injury in children is trauma. Chronic pancreatic insufficiency usually occurs secondary to CF.

Introduction Coexistence of pulmonary embolism and systemic arterial embolism suggest the diagnosis of paradoxical embolism which suggests the presence of intracardiac defects such as patent foramen ovale (PFO). Case presentation A 42 year old man was found to have a paradoxical embolism in the systemic arterial circulation, in the setting of pulmonary embolism and deep vein thrombosis (DVT) in the lower extremities. Conclusion Paradoxical embolism and intracardiac shunt should be immediately considered in a patient with pulmonary embolism and systemic arterial embolism. Diagnostic modalities included arteriogram and saline contrast echocardiography. Closure of intracardiac shunt is needed for patients who are at risk for recurrent embolic events.

The role of Helicobacter pylori in the pathogenesis of duodenal and gastric ulcer and ulcer recurrence is widely known. Bleeding, perforation, and gastric outlet obstruction represent the most serious, potentially life-threatening complications of ulcer disease. At present, the effect of H. pylori eradication on complicated ulcer disease has not been fully established. Case reports exist on the resolution of gastric outlet obstruction after eradication of H. pylori. We report the first case of H. pylori-related gastric outlet obstruction successfully treated with parenteral antibiotics.

Mesenteric venous thrombosis (MVT), an uncommon but important clinical entity, is one possible cause of ischemia or infarction of the small intestine. Diagnosis of this condition is sometimes difficult and treatment is often delayed because patients usually present with nonspecific abdominal symptoms. The hallmark is pain that is out of proportion to the physical findings. We report two cases of MVT, where the patients initially presented with vague abdominal symptoms. Diagnosis was made on the basis of computed tomography of the abdomen showing thrombus within the superior mesenteric vein. A search for a precipitating condition revealed no evidence of a hypercoagulable state, myeloproliferative disorder, or malignancy. These cases illustrate well the nonspecific clinical presentation of MVT. A high index of suspicion, recognition of known risk factors, or a previous history of venous thrombosis coupled with a history of nonspecific abdominal symptoms should alert clinicians to the possibility of MVT. Early diagnosis and prompt anticoagulation are the mainstay of therapy unless there are signs of peritonitis that necessitate surgical resection of the infarcted bowel.

A 28-year-old woman with nausea, vomiting, and abdominal pain had been hospitalized elsewhere on 13 separate occasions over the year before this admission for similar episodes thought to be secondary to acute pancreatitis. She had undergone repeated work-ups including endoscopic retrograde cholangiopancreatography, computed tomographic scan, and exploratory laparotomy. There was a discrepancy between her unremarkable physical examination and extremely elevated amylase (3,210 U/L) which suggested nonpancreatic hyperamylasemia; normal serum pancreatic isoamylase, trypsinogen, and lipase confirmed this suspicion. The patient was noted to have self-induced vomiting in the hospital which she admitted was frequent behavior. her psychiatric disturbance was characterized as an atypical eating disorder. This case illustrates that hyperamylasemia in association with abdominal pain, nausea, and vomiting may not be secondary to pancreatitis and that use of a second serum marker (such as trypsinogen, lipase, or isoamylase) helps to establish a definitive diagnosis.

TO THE EDITOR: Primary hepatocellular carcinoma is occurring with increasing frequency in the United States, as recently shown in a study (1). Chronic hepatitis B and C infection leading to cirrhosis are believed to be responsible for this increased incidence (1, 2). In context of these findings, we would like to report the results of a small retrospective study recently conducted at our institution.

Foreign bodies of the esophagus in adults may be the result of a food bolus that becomes lodged proximal to a structural abnormality of the distal esophagus. A case of peptic stricture of the esophagus in a patient who presented with acute dysphagia after ingesting an over-the-counter diet pill composed of guar gum is discussed. It is recommended that anorectics composed of dietary fiber should not be used in patients with a history of esophageal stricture.

Appropriateness and timing of antibiotic prophylaxis for endoscopic procedures: results of a national survey

A rapid, sensitive and convenient fluorescent assay was developed to screen for lipase activity. The non-fluorescent substrate, 4-methylumbelliferyl butyrate (4-MUB), solubilized in either liposomal dispersions or bile salt/lecithin mixed micelles, is hydrolyzed to butyric acid and the highly fluorescent compound, 4-methylumbelliferone (4-MU). Assays are run at 37 C for 10 min, terminated, and the changes in fluorescence quantitated with a Turner III fluorometer. Both lingual and pancreatic lipases exhibit activity against this artificial substrate. The assay has several advantages: nmoles 4 MU/ml/hr are measured allowing the detection of very low lipolytic activity; multiple samples may be simultaneously assayed, and only a brief incubation period is required.

To explore the secondary structures of lingual and pancreatic lipases, circular dichroism measurements were performed. Maximum average ellipticities were used to calculate the percentage of alpha-helices, beta-sheets, and random coils. Lingual lipase had an ellipticity of -20235 +/- 140 deg cm2/dmol (mean +/- SE) at 220 nm suggesting 60% alpha-helix, 20% beta-sheet and 20% random coil structure, but the mean ellipticity for pancreatic lipase was -14093 +/- 82 deg cm2/dmol (mean +/- SE) at 210 nm suggesting a 34.8% alpha-helical, 25% beta-sheet and 40% random coil secondary structure. An alpha-helical stretch of residues with a large hydrophobic moment ("globular" alpha-helix by hydrophobic moment plot) from amino acids 382 through 389 at the COOH-terminal end of lingual lipase was noted. This sequence, absent in pancreatic lipase, may account for the avid binding of lingual lipase to fat emulsion particles.

We retrospectively reviewed the charts of 308 admissions to a pulmonary disease ward and 100 admissions to the general medical service over one year to find the prevalence, sequelae, and etiology of hypophosphatemia. The overall prevalence of low serum phosphate levels (less than 2.4 mg/dl) occurring at least once during hospitalization in chest patients was 17 percent, but was higher in patients with respiratory infections (28 percent). Moreover, the prevalence of hypophosphatemia on admission (before institution of intravenous fluid or drug therapy) was ten times higher in patients with respiratory infections than in patients with noninfectious respiratory illness or general medical patients (21 vs 2 percent, p less than 0.001). Serum phosphate less than 2.0 mg/dl occurred in 4 percent of patients. Twenty-seven percent of the patients (including two with ventilatory failure) with abnormally low serum phosphate levels had symptoms or signs of uncertain etiology later explicable by the presence of hypophosphatemia. The most common additional laboratory finding associated with hypophosphatemia was elevation of muscle enzymes. Although mortality was no higher in hypophosphatemic patients, hospital stay was twice as long as that of patients with normal levels of serum phosphate. No correlation was found between simultaneous arterial blood gases and serum phosphate levels. Two patients given antacids had severe hypophosphatemia and worsened ventilatory function; phosphate-binding antacids should be used judiciously in patients with severe respiratory disease, since they may lead to the development or worsening of hypophosphatemia and diminished ventilatory function.

PreviewSteatorrhea is the hallmark of malabsorption. Microscopic examination of stool using Sudan stain is an inexpensive, sensitive, and specific screening test for steatorrhea, and the 72-hour quantitative determination of fecal fat in stool definitively establishes the presence of malabsorption. From this point on, the workup follows the simple sequence outlined by Dr Roberts to determine whether the source of malabsorption is intestinal disease or abnormalities, pancreatic disease, or bacterial overgrowth.

Summary Fat malabsorption in patients with chronic alcoholic pancreatitis and cystic fibrosis may lead to vitamin and essential fatty acid deficiency in addition to steatorrhea. In clinical practice it can be difficult to achieve complete correction of malabsorption and elimination of steatorrhea. The earliest treatment methods used the oral administration of porcine pancreatic enzyme preparations. These conventional enzymes, however, were unstable in the acidic intragastric environment. Subsequently, medications to neutralize or reduce gastric acidity (H,-blockers, antacids, or bicarbonate) were added to improve the stability of the conventional enzymes. Enteric-coated enzyme preparations were then developed that would release only in an alkaline milieu, protecting the enzymes from acid denaturation. The newest and potentially most exciting modalities for the treatment of fat malabsorption are acid-stable lipases, obtained either from a fungal source or through the expression of cloned genes for the enzymes utilizing recombinant DNA techniques. The advantages and disadvantages of the various medications for the therapy of fat malabsorption in pancreatic insufficiency are reviewed.

We explored the utility of fecal fat concentration (gram fecal fat per 100 gram wet stool weight) as a screening test for pancreatic steatorrhea. Data were analyzed on 24 patients with pancreatic insufficiency and steatorrhea, six groups of patients (N = 70) with nonpancreatic causes of steatorrhea, and 31 controls without steatorrhea. Patients with pancreatic steatorrhea had significantly (P less than 0.05) higher mean fecal fat concentrations than all groups except for patients with hepatobiliary disease. Using a fecal fat concentration of greater than 9.5% as a cutoff point in all patients with steatorrhea, the test was 41.7% sensitive and 92.0% specific for the diagnosis of pancreatic insufficiency. For patients with fecal fat excretion greater than 20 g/day, the test increased in sensitivity to 61.5% but specificity dropped to 85.3%. Measurements of fecal fat concentrations are therefore only moderately helpful, and further evidence is required to secure a diagnosis of pancreatic steatorrhea.

Rat lingual lipase was purified to homogeneity by solubilization in 1% octylglucoside, followed by centrifugation, affinity chromatography on hydroxylapatite, gel filtration, and chromatofocusing. Polyclonal antibodies to the enzyme were raised in rabbits, and monospecificity was established by immunoblotting. Tissues were embedded in either paraffin or Epon for light and transmission electron microscopy, respectively. Immunocytochemical localization of the enzyme was established using the peroxidase-antiperoxidase and streptavidin-gold techniques. Immunospecific staining was observed in all acinar cells of the serous von Ebner glands, but only in the demilunes of the lingual mucous glands. The secretory granules of the acinar cells of the von Ebner glands were stained with antilipase on electron microscopic examination. No staining was observed in the salivary glands, pancreas, esophagus, stomach, or duodenum. If a true gastric lipase exists in the rat, it is immunogenically distinct from lingual lipase.

The ontogeny of the rat lingual serous and mucous glands was explored by light and electron immune microscopy using the peroxidase-antiperoxidase and streptavidin-gold techniques. Tissues from fetal and neonatal rats from day 18 of gestation through 4 wk after birth were fixed and embedded in paraffin or Epon for light and transmission electron microscopy, respectively. Electron microscopy revealed that the only cells containing lingual lipase were the developing serous cells; secretory granules containing lingual lipase of varying degrees of maturity were seen. Mucous cells did not show immunospecific staining in rats of any age. The neonatal “mixed” lingual glands secrete lingual lipase from serous components immediately after birth to aid in fat digestion.

A 40-yr-old woman with celiac sprue, which had responded clinically and histologically to gluten elimination, subsequently developed gastrointestinal lymphoma. Although this has been described in the small intestine of patients with celiac sprue, the unique feature in this patient was her initial presentation with multiple gastric ulcers refractory to conventional medical therapy. This case demonstrates that lymphoma complicating celiac sprue may present with multiple refractory gastric ulcers in addition to those occurring in the small intestine.

• A 37-year-old homosexual man was evaluated for a one-week history of hematochezia. Results of a physical examination were remarkable only for grossly bloody stool. Sigmoidoscopy to 30 cm showed a friable mucosa compatible with an acute colitis, and a rectal biopsy specimen demonstrated an increased plasma cell infiltrate. Stool cultures subsequently yieldedAeromonas hydrophila; serum human T-cell lymphotropic virus type III antibody titer was positive. The patient responded to a course of treatment with sulfamethoxazole and trimethoprim with resolution of his symptoms and restoration of the bowel to a normal sigmoidoscopic appearance.Aeromonas hydrophilainfection should be considered in the differential diagnosis of acute proctocolitis, particularly in patients with underlying immunodeficiency states. (Arch Intern Med1987;147:1502-1503)