Category Archives: Health

Management of An Extensive Tracheoesophageal Fistula by Cervical Esophageal Exclusion (8)

Torqueing of tracheostomy tubes from malpositioned ventilator circuits should also be avoided. Prolonged nasogastric intubation with standard sump drainage systems is a serious management error of patients requiring extended endotracheal intubation. Soft, small diameter nasoenteral feeding tubes should be used in lieu of the larger and harder sump tubes. If an intermittent abdominal ileus is a problem, we recommend performing percutaneous or standard surgical gastrostomy to provide gastrointestinal access or decompression. (more…)

Different profile of interleukin-10 production: PATIENTS AND METHODS (4)

Staining Cells were washed and suspended at a density of 1x106 cells in 100 pL of PBS with 0.1% sodium azide and 5% normal mouse serum (Sigma, USA), and incubated for 10 min on ice; this was followed by surface staining with anti-CD3 mAb and antiCD4 mAb/anti-CD8 mAb for 20 min on ice in the dark. For intracellular cytokine staining, the cells were washed and fixed in 100 pL of fixation buffer (Caltag, USA) containing 4% paraformaldehyde for 20 min on ice. (more…)

Intractable diarrhea in a newborn infant: DISCUSSION Part 2

DISCUSSION While the basic defect is unknown, it has been proposed that the ultrastructural lesion that characterizes MID is best explained as an example of a normal cell component assembled in an abnormal location. The microvilli appear to be assembled on the inner surface of the intracytoplasmic vesicles rather than at the apical cell surface. Furthermore, the prominent periodic acid-Schiff staining of the apical cytoplasm (rather than the brush border), the immunofluores-cent staining of specific brush border enzymes in the apical cytoplasm and the accumulation of secretory granules in the apical region of some cells all suggest that an abnormality of exocytosis exists. Brush border proteins normally reach the plasma membrane at the base of the apical microvilli. They are synthesized in the rough endoplasmic reticulum, processed and assembled as membrane proteins in the Golgi apparatus, and transported to the cell surface along a chain of connecting intracytoplasmic vesicles. However, against this theory, normal exocytosis and localization of two brush border-targeted enzymes (sucrase-isomaltase and dipeptidylpeptidase intravenous) have been demonstrated in biopsies and organ cultures from MID patients. These studies suggested that both direct and indirect constitutive pathways of exocytosis were intact in MID. It was hypothesized that there may be an as yet uncharacterized regulated pathway of exocytosis in enterocytes that is abnormal in MID. (more…)

Intractable diarrhea in a newborn infant: DISCUSSION Part 1

DISCUSSION The initial report of an apparently familial enteropathy, characterized by protracted diarrhea from birth and hypoplastic villous atrophy, was in 1978 by Davidson et al. Electron microscopy of surface enterocytes from a jejunal biopsy specimen of one of their patients revealed intracytoplasmic inclusions composed of neatly arranged brush border microvilli. Similar inclusions have since been reported in other children presenting with protracted watery diarrhea starting soon after birth. The term ‘MID’ was proposed to designate the condition because it highlights the characteristic ultrastructural lesion and clearly differentiates the condition from other entities. The condition appears to be inherited as an autosomal recessive disorder. While consanguinity was not present in our case, Candy et al found that 20% of infants with this disease were the products of consanguineous relationships, and three of the nine infants reported by Cutz et al had a sibling affected. A high frequency of MID in the Navajo Indian population of Arizona has been observed. While uncommon, MID is the most common cause of severe refractory diarrhea in the neonatal period in North America. (more…)

Intractable diarrhea in a newborn infant: CASE PRESENTATION Part 2

Intractable diarrhea in a newborn infant A barium study showed no evidence of a congenital short bowel or an obstruction. Hirschsprung’s disease was excluded when a full thickness rectal biopsy showed normal ganglion cells. Urinary catecholamines were assessed to rule out a neuroendocrine tumour and were reported to be in the normal range. Assessments revealed no immunological abnormality. At four months of age, when the patient weighed 3.0 kg, endoscopic duodenal biopsies were obtained. With examination by light microscopy, sections of small intestinal mucosa exhibited partial to total villous atrophy, a hypocel-lular lamina propria and crypt hypoplasia. The poorly defined brush border in the surface epithelium and the periodic acid-Schiff positivity of the apical cytoplasm of the entero-cytes suggested MID. Suction biopsies of the rectal mucosa were unremarkable. Because of the increased risk of perforation associated with suction jejunal biopsies in malnourished infants, repeat jejunal biopsy with a Carey capsule and primary fixation of tissue for electron microscopy were delayed until the child was six months of age and weighed 5.5 kg. Electron microscopic evaluation of this second proximal small intestinal biopsy revealed intracytoplasmic microvillous inclusion bodies, confirming the diagnosis of MID (Figure 1). (more…)

Intractable diarrhea in a newborn infant: CASE PRESENTATION Part 1

Intractable diarrhea in a newborn infant A nine-day-old white male presented with a history of watery diarrhea that had developed gradually in the first few days after birth. He was born to nonconsanguineous parents at 36 weeks’ gestation. The pregnancy was uncomplicated, with no evidence of polyhydramnios. There was meconium-stained liquor at delivery, but the immediate postnatal period was uneventful. Birth weight was 2.74 kg. The patient was discharged on day 3 weighing 2.43 kg. At home, he was breastfed every 2 to 3 h and continued to have three stools per day, of which at least one was described as watery. On day 9, he was brought to the hospital because he was lethargic and feeding poorly. In the emergency room, he was noted to be poorly responsive and was estimated to be 10% dehydrated, weighing only 1.8 kg. The physical examination was otherwise unremarkable. He was hypernatremic and acidotic, with a capillary blood pH of 6.97 but only a modest anion gap of 22 mmol/L (normal 5 to 15 mmol/L). Oral feeding was stopped, and fluids were replaced intravenously. Bicarbonate was infused to partially correct the acidosis. Broad spectrum antibiotic therapy was initiated after cultures were taken. Of the many possible causes of watery diarrhea (Table 1), a viral or allergic enteropathy was initially considered to be most likely. However, stool cultures and rapid screens for rotavirus and adenovirus were subsequently negative. Blood, urine and cerebrospinal fluid were sterile. (more…)

Peptic disease in elderly patients: TREATMENT Part 2

TREATMENT The present mainstays of treatment for peptic ulcer disease are the H2 receptor antagonists, PPIs, anti-H pylori treatment or cytoprotective agents such as sucralfate. Histamine receptor-blocking agents are still the most widely used agents for the treatment of peptic disease in elderly patients. These drugs work by direct suppression of gastric acid secretion - mainly nocturnal acid secretion. H2 receptor antagonists have an extremely low side effect profile, and several preparations can be administered only once or twice daily. Dosage adjustment is needed only in patients with renal or hepatic disease even in older patients. There have been no proven difference in the adverse reaction profiles of different H2 receptor antagonists in elderly patients. In particular, ci-metidine causes no more confusion, depression, memory impairment or hallucinations than other H2 receptor antagonists. A meta-analysis of adverse reactions to ci-metidine totalling over 600 patients showed no significant differences in side effects between patients treated with ci-metidine or controls. (more…)

Peptic disease in elderly patients: TREATMENT Part 1

TREATMENT Early recognition and precise diagnosis are crucial to provide effective treatment of elderly patients with peptic ulcer disease. The failure to diagnose peptic disease rapidly complicates timely therapy. Patients of all ages with peptic ulcer disease should be advised to stop smoking, eliminate alcoholic beverages on an empty stomach and eat regular meals. If H pylori is diagnosed, this infection should be treated in all patients with a peptic ulcer. If H pylori is not eradicated by the initial treatment regimen, patients need to be retreated one to two months later because eradication of H pylori has been shown to reduce the rate of peptic ulcer relapse markedly. The most common reason for H pylori treatment failure is noncompliance, which occurs frequently in the elderly population. Therefore, the simpler the regimen and the shorter the length of treatment the better the results. The newer regimens that include omeprazole, amoxycillin, and metronidazole or clarithromycin for 10 days are as effective as and better tolerated than earlier triple therapy regimens that included colloidal bismuth and required two to three weeks of treatment. (more…)

Peptic disease in elderly patients: EVALUATION

EVALUATION Initial tests for patients with peptic symptoms include eso-phagogastroduodenoscopy and upper gastroduodenal barium study. Endoscopy has been shown to be more accurate than barium studies in the diagnosis of peptic diseases in elderly patients, just as in young patients. Endoscopy is well tolerated and safe, even in very old patients. Caution is warranted during sedation in elderly patients, as in younger patients with cardiovascular or pulmonary diseases, and monitoring of oxygen saturation is mandatory. In elderly patients, barium studies can be used to evaluate some upper gastrointestinal complaints if endoscopy is contraindicated because of medical conditions that make sedation dangerous, such as a recent myocardial infarction. At all ages, the advantages of endoscopy include the ability to take mucosal biopsies for the diagnosis of H pylori, and to determine the pathology of gastric ulcers and the ability to visualize directly esophagitis and duodenitis. Most patients prefer endoscopy to barium radiology, especially elderly patients who are frail and have difficulty moving around. (more…)

Peptic disease in elderly patients: CLINICAL MANIFESTATIONS Part 4

H pylori H pylori: It has long been recognized that there is an association among H pylori, gastritis and peptic ulcer disease. Antibodies to H pylori infection are found in over 50% of people in developed countries who are older than 60 years of age. In one study, the prevalence was found to approach 90% in patients over the age of 60 years. In elderly patients, H pylori infection is usually the cause of gastritis. The most important cause of H pylori-negative gastritis appears to be overt or covert NSAID ingestion. (more…)