Postgrad Med

Ulcerative colitis in young adults. Complexities of diagnosis and management.

Kam L.
University of Southern California School of Medicine, Los Angeles 90033, USA.
Ulcerative colitis should be considered in any patient with chronic diarrhea or rectal bleeding. Diagnosis depends on a combination of findings from physical, laboratory, endoscopic, and histopathologic examinations, together with the exclusion of other causes and continued observation over time. The mainstays of treatment are sulfasalazine for mild to moderate disease and corticosteroids for moderate to severe disease. Side effects of sulfasalazine, due to the sulfa moiety of the drug, limit its use in some patients. Newer, sulfa-free 5-ASA agents, although expensive, are appropriate for patients who cannot tolerate sulfasalazine. Refractory ulcerative colitis is best treated surgically. Most patients require maintenance therapy with sulfasalazine or a sulfa-free 5-ASA preparation. Cancer risk is increased in patients with long-standing ulcerative colitis.

Enterohemorrhagic Escherichia coli. A dangerous food-borne pathogen.

Qadri SM. Kayali S.
Microbiology Laboratories, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Qadri@kfsh&rc.edu.sa
Since 1982, several outbreaks of hemorrhagic colitis due to EHEC, or E coli O157:H7, have occurred in the United States and other parts of the world. Contaminated, undercooked ground beef has been most frequently implicated in the outbreaks, although unpasteurized dairy products and other foods have also been the source of infection in sporadic cases. The most common clinical manifestation of EHEC infection is abdominal cramps and watery, bloody diarrhea. HUS secondary to the initial colitis develops in about 10% of patients under 10 years of age. Definitive diagnosis is made by isolation and identification of EHEC in stool samples. Treatment focuses on rehydration and supportive therapy. The use of antimicrobial agents, narcotics, or antimotility agents is not recommended, because they neither shorten the course of illness nor prevent the development of sequelae.

Complications of cirrhosis. Why they occur and what to do about them.

McGuire BM. Bloomer JR.
Liver Center, University of Alabama at Birmingham 35294-0005, USA. joseph_bloomer@gasmac.dom.uab.edu
Cirrhosis is a chronic disease of the liver in which dense bands of fibrosis enclose regenerative hepatocellular nodules. Clinical and radiologic features of advanced liver disease provide presumptive evidence for the presence of cirrhosis. Major complications are related to the increased hepatic resistance, increased sodium and water retention, and hyperdynamic changes of the circulatory system. Patient management should consist of appropriate prophylaxis for the life-threatening complications of variceal bleeding and spontaneous bacterial peritonitis and treatment of other complications as signs and symptoms develop.

Helicobacter pylori and peptic ulcer disease. Bridging the gap between knowledge and treatment.

Year 1998
Laine L. Fendrick AM.
Department of Medicine, University of Southern California School of Medicine, Los Angeles 90023, USA.
Eradication of H pylori and cure of peptic ulcer disease are possible if effective regimens are used correctly. Treatment markedly improves clinical outcomes and significantly decreases cost of care. As primary care physicians take a larger role in management of these infections, they need to understand the importance of identifying and treating patients with H pylori-associated peptic ulcer disease. Successful treatment of this infection depends on the appropriate antimicrobial therapy and patient compliance with the chosen regimen.

Hereditary angioedema. Complex symptoms can make diagnosis difficult.

Year 1998
Borum ML. Howard DE.
George Washington School of Medicine and Health Sciences, Washington, DC 20047, USA.
Although rare, hereditary angioedema is a potentially life-threatening disorder that can be difficult to diagnose. It is characterized by a deficiency in C1 esterase inhibitor (C1 INH). Manifestations include gastrointestinal, subcutaneous, and respiratory edema. Factors that trigger episodes vary. Symptoms typically last 48 to 72 hours, but they can last 4 hours to 1 week. Treatment includes prophylactic therapy with attenuated androgens or antifibrinolytic agents. Acute episodes can be medical emergencies, and airway management is a major concern. The treatment of choice in an acute episode is administration of plasma concentrate of C1 INH.

Alcoholic liver disease. Treatment strategies for the potentially reversible stages.

Year 1998
Hill DB. Kugelmas M.
Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington 40536-0084, USA. dahill0@pop.uky.edu
Even modest alcohol ingestion can increase the risk of steatosis, and long-term, excessive consumption can lead to alcoholic hepatitis and eventually cirrhosis. Most patients with clinically significant alcoholic liver disease have histologic findings typical of all three conditions. The only clearly beneficial treatment is abstinence from alcohol. Abstinence in combination with proper nutrition and general supportive care is state of the art. Steatosis is reversible upon withdrawal of alcohol, but alcoholic hepatitis can persist even with abstinence and may progress to cirrhosis. Corticosteroid therapy may reduce short-term mortality rates in patients with moderate or severe alcoholic hepatitis who have hepatic encephalopathy but no evidence of infection or gastrointestinal bleeding. Treatment with colchicine may decrease the risk of cirrhosis; however, once cirrhosis has developed, the liver damage is irreversible. The prognosis is improved with abstinence, but complications (e.g., ascites, gastrointestinal bleeding) often occur. Liver transplantation may be considered in patients with severe complications.

Update on upper gastrointestinal bleeding. Basing treatment decisions on patients risk level.

Year 1998
Terdiman JP.
University of California, San Francisco School of Medicine, USA. jterd@itsa.ucsf.edu
Acute upper gastrointestinal bleeding is a common reason for hospitalization. Mortality rates range from 5% to 15%; patients with severe comorbidities and those with persistent or recurrent bleeding are at highest risk. Accurate preliminary risk assessment and resuscitation can proceed simultaneously at initial presentation. Risk assessment can guide treatment decisions. Early upper gastrointestinal endoscopy, a cornerstone of management, allows for rapid diagnosis, application of endoscopic therapy, and completion of risk assessment. Endoscopic therapy can alter the natural history of upper gastrointestinal bleeding by reducing rates of further bleeding and, consequently, mortality. Complete risk assessment of both clinical and endoscopic factors can likely result in shorter hospital stays and improved outcomes. Early assessment helps identify low-risk patients in whom discharge on the day of presentation is appropriate.

Inflammatory bowel disease. 1. Origins, presentation, and course.

Year 1998
Moses PL. Moore BR. Ferrentino N. Bensen SP. Vecchio JA.
Section of Gastroenterology and Hepatology, University of Vermont College of Medicine, Burlington 05405-0068, USA.
The exact cause of inflammatory bowel disease remains undiscovered, but its destructive nature is clearly recognized. In this article, the authors summarize what is known about the pathogenesis and epidemiology of ulcerative colitis and Crohn's disease and how to distinguish between the two, both clinically and pathologically. They also describe disorders that may mimic inflammatory bowel disease. In part 2 of this article, beginning on page 86, the authors discuss some of the therapeutic options that are the commonly used as well as some that are investigational but show promise for patients with this chronic and relapsing disease.

Inflammatory bowel disease. 2. Current and future therapeutic options.

Year 1998
Moses PL. Moore BR. Ferrentino N. Bensen SP. Vecchio JA.
No information.
The exact source of interference with the normal protective immune response in patients with inflammatory bowel disease remains unclear. Infectious causes have been proposed, and the increased incidence among family members indicates genetic predisposition. No matter what the pathogenesis may be, the disease is chronic, recurrent, and destructive in many cases. Conventional therapy with 5-ASAs, corticosteroids, immunomodulating agents, methotrexate, and antibiotics often offers relief. However, adverse effects accompany long-term use of many of these agents, so follow-up is important. Much investigation of alternative methods is under way, and anecdotal as well as published experience suggests benefits in at least some patients. Because of the chronic nature of their condition, patients with inflammatory bowel disease often become quite sophisticated in their understanding of treatment methods. Therefore, they should be told of updates regarding new options for disease control. We recommend that patients be seen periodically by a gastroenterologist who has expertise in inflammatory bowel disease, even when the disease is quiescent. Our experience in observing these patients over time strongly supports use of some of the agents discussed in this article for prophylaxis against flares and chronic inflammation.