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Esophageal hemorrhage pancreatitis

ES^W^^^s'^

due to

To the editor: Pancreatitis

as a cause

is exceedingly uncommon but should be considered in cases of hematemesis.

of

esophageal bleeding

A male chronic alcoholic

aged 70 was admitted to a regional hospital with hema¬ temesis of sudden onset. He had a long history of intermittent abdominal pain, nausea, anorexia, weight loss and occa¬ sional vomiting. Several months previously a diagnosis had been made of chronic pancreatitis, supported by radiographic evidence of calcification in the pancreas

(Fig. 1). The patient was weak and sweating. His hemoglobin value was 9.9 g/dl, increasing to 11.9 g/dl after blood transfusion. The leukocyte count was 18 x 107/ (77% neutrophils). Blood glucose value was 192 Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double spaced and should not exceed XVi pages in length.

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mg/dl; serum bilirubin, 4.5 mg/dl (direct, 3.6 mg/dl); serum amylase, 200 U// (nor¬ mal, 60 to 160 U//); serum calcium, low at 8.1 mg/dl. Prothrombin time and values of serum electrolytes, serum lipids and blood urea nitrogen were normal. The liver appeared to be slightly enlarged. Radiographic appearance of the distal eso¬ phagus suggested a "long ulcer crater" (Fig. 2) but the stomach and duodenum were unremarkable. The patient continued to vomit bright red blood and clots intermittently. He was admitted to the Hamilton General Hos¬ pital and given repeated blood transfu¬ sions. Fibre-endoscopy showed an "ulcer¬ ated haemorrhagic lesion" in the lower part of the esophagus but biopsy material consisted of only blood clot and no neo¬ plastic tissue. Control of the bleeding with a Blakemore tube was attempted but with¬ out success. Hematemesis continued and, despite further transfusions, the patient died 2 days later. Autopsy was performed 12 hours after

death. The pancreas (weight, 110 g) was approximately normal in size and shape but its dilated main duct contained several calculi and mucopurulent fluid. Small ab¬ scesses were also present in the pancreas and culture yielded a heavy growth of Escherichia coli and a light growth of

Clostridium perfringens. There was a vari¬ able excess of fibrous tissue. Near the tail was a thin-walled pseudocyst, 3 cm in diameter, filled with blood clot. Blood had escaped from this cavity and tracked upwards to rupture into the esophagus. The latter was 26 cm long and its lumen was distended by blood clot in the lower third, where the wall was "dissected" by blood and the mucosa torn irregularly over an area approximately 2.5 cm long and 1.0 cm broad. No varices were seen. Much blood was present in the stomach and throughout the intestine. Some pericholangitis was observed in the liver (weight, 1225 g) but there was no cirrhosis. Dense fibrous adhesions surrounded the spleen (weight, 100 g). No aneurysm or other abnormality was present in splenic vessels.

Hematemesis or melena associated with pancreatitis is rare.1 Such bleeding can be mild or severe and either a sol¬ itary event or repeated. Its explanation may be obscure.

Gambill, Baggenstoss and Priestley2 found that upper gastrointestinal tract hemorrhage had occurred in 9 of 29 patients with chronic relapsing pancre¬ atitis, without gastrointestinal or biliary disease, at the end of a 16- to 20-year follow-up. Trapnell,3 reviewing the rec¬ ords of 581 patients with pancreatitis, found that 10 had had acute gastro¬ intestinal tract bleeeding and in 8 it was a terminal event in a long illness.

FIG. 1.Calcification (arrows) in pancreas.

FIG. 2."Ulcerated lesion" in terminal part of esophagus.

Muether and Knight* recorded he¬ matemesis or melena in 23% of 58 patients with chronic recurring pan¬ creatitis. Radiologic studies showed no abnormalities, but gastroscopy in one patient demonstrated hemorrhagic gas¬ tritis. They also referred to occasional cases in which bleeding followed ero-

CMA JOURNAL/OCTOBER 4, 1975/VOL. 113 605

sion of the duodenum by a pancreatic calculus. Gastric or esophageal erosions and varices are common in alcoholics with or without pancreatitis. A bleeding peptic ulcer may also be coincidental in patients with pancreatitis. In pancreatitis, bleeding in and around the pancreas may be the consequence of a necrotizing and suppurative, possibly infective, process. Bleeding may be associated with a pancreatic pseudocyst: adjacent blood vessels become incorporated in its wall and may be eroded by digestive enzymes, with resulting thrombosis or pseudoaneurysm formation; surgical management is often necessary.3 Sometimes bleeeding esophageal varices in patients with pancreatitis may be related to splenic or portal vein thrombosis and can be successfully treated by surgery. Cotton and colleagues5 described a man of 45 with a pancreatic pseudocyst whose main problem was gastrointestinal tract bleeding and in whom splenoportography, celiac-axis angiography and fibre..endoscopy revealed gastric varices due to splenic vein thrombosis. The bleeding stopped after splenectomy. They stated that splenic vein obstruction can be demonstrated in as many as 54% of patients with pancreatitis in France. Our patient had chronic active pancreatitis but no disease of stomach or duodenum. Blood from a pseudocystic cavity near the tail of the pancreas had tracked upwards retroperitoneally and dissected the lower esophagus before entering the lumen. The exact identification of pancreatitis as a source of hemorrhage may be difficult and the indications for surgical intervention pose considerable problems. Nevertheless, full investigation, including angiography, is recommended. Hemorrhage attributable to pancreatitis carries such a high mortality that survival may depend on a combined medical and surgical approach that is thorough and vigorous. M.F. CASTELLI, MD, PRCP[CJ J.D. HAMILTON, MB, ES, MRCP, FRCP[CJ A. WYNN-WILLIAMS, MD, PH D FRC PATH, PRCP(C&E]

McMaster University clinical teaching units in medicine and pathology Hamilton General Hospital Hamilton. Ont.

References 1. GAMBiLL EE: Pancreatitis, St Louis, Mosby, 1973, p 227 2. GAMBILL EE. BAGGENSTOSS AH, PRIESThEY JT: Chronic relapsing pancreatitis: fate of fifty-six patients first encountered in the years 1939 to 1943, inclusive. Gastroenterology 39: 404, 1960 3. TRAPNELL J: Management of the complications of acute pancreatitis. Ann R Coil Surg Engi 49: 361, 1971 4. MUETHER

RO.

KNIGHT

WA

JR:

Chronic

recurrent pancreatitis, clinical and laboratory aspects. Gastroenterology 12: 24. 1949 5. Co.roN PB. Naous D. Baowsa NL, et al: Gastrointestinal bleeding in pancreatitis. Lance: 1: 847. 1972

Safety of retinoic acid in acne therapy To the editor: Topical retinoic acid (vitamin A acid) has been in worldwide use for the past 5 years and has gained an excellent reputation as an effective treatment for acne vulgaris. Since Stiittgen1 first reported the efficacy of topical retinoic acid the results have been confirmed in a controlled clinical trial.2 In Great Britain, France, the Netherlands, Switzerland, the United States, Australia and other countries it has been available as a lotion or cream and has been marketed without teratogenic warnings. In Canada the drug is not available because of the claimed potential teratogenicity in man.3 The basis for this judgement was cited to be the results of laboratory studies on mice, rats and hamsters, in which teratogenic effects were observed after oral administration of the drug. Is retinoic acid teratogenic for man? DeLuca and Roberts4 showed that retinoic acid is an intermediate in the metabolism of retinol or vitamin A. Olson5 has described similar findings. Giroud6 concluded that teratogenic action of retinoic acid is found in several species but in different degrees, and stated "It is very probably absent in man." To date there are no reports in the medical literature that vitamin A acid has been associated with teratogenicity in man through topical or systemic use, nor has teratogenicity been documented in man from the use of vitamin A. The Canadian Council on Nutrition has recommended the administration of 4200 IU daily of vitamin A during pregnancy. Manufacturers of vitamin A recommend the avoidance of oral doses greater than 10 000 IU daily for children, adolescents and pregnant women, again on the grounds of teratogenic malformations in animals. (Units of vitamin A acid are considered roughly equivalent to units of vitamin A.) The usual topical therapy for acne may require 30 to 60 ml/mo of a 0.1 % solution of retinoic acid or a daily topical dose of 1 to 2 mg (1000 to 2000 IU). While absorption of the drug is variable because of its effect on the absorption barrier, systemic absorption was found not to exceed 50% in studies reported at the International Symposium on Vitamin A Acid in Switzerland in 1975. Since vitamin A acid is an intermediate in the metabolism of vitamin A, since no teratogenicity has been reported in man from vitamin A or vitamin A acid therapy in spite of worldwide use in males, in females and in pregnant females, and since the systemic absorption from topical applica-

606 CMA JOURNAL/OCTOBER 4, 1975/VOL. 113

SEPTRA (Trimethoprim + Sulfamethoxazole)

* sequentially blocks two different bacterial enzymes (both vital for bacterial survival) * double blockade activity discourages development of resistance * achieves rapid, high blood levels; significant levels in lung tissue and sputum * well tolerated by most patients * convenient b.i.d. tablet dosage * licorice-flavored suspension well accepted by children * SEPTRA R. Summary INDICATIONS AND CLINICAL USES: Indicated for the following infections when caused by susceptible organisms: URINARY TRACT INFECTIONS - acute, recurrent and chronic. GENITAL TRACT INFECTIONS - uncomplicated gonococcal urethritis. UPPER AND LOWER RESPIRATORY TRACT INFECTIONS particularly chronic bronchitis and acute and chronic otitis media. GASTROINTESTINAL TRACT INFECTIONS. SKIN AND SOFT TISSUE INFECTIONS. SEPTRA is not indicated in infections caused by Pseudomonas, Mycoplasma or viruses.This drug has not yet been fully evaluated in streptococcal infections. CONTRAINDICATIONS: Patients with evidence of marked liver parenchymal damage, blood dyscrasias, known hypersensitivity to trimethoprim or sulfonamides, marked renal impairment where repeated serum assays cannot be carried out: premature or newborn babies during the first few weeks of life. For the time being SEPTRA is contraindicated during pregnancy. If pregnancy cannot be excluded, the possible risks should be balanced against the expected therapeutic effect. PRECAUTIONS: As with other sulfonamide preparations, critical appraisal of benefit versus risk should be made in patients with liver damage, renal damage, urinary obstruction, blood dyscrasias, allergies or bronchial asthma. The possibility of a superinfection with a non-sensitive organism should be borne in mind. DOSAGE AND ADMINISTRATION: Adults and children over 12 years. Standard dosage: Two tablets twice daily (morning and evening). Minimum dosage and dosage furlong-term treatment: One tablet twice daily. Maximum dosage: Overwhelming infections: Three tablets twice daily. Uncomplicated gonorrhea: Two tablets four times daily for two days. Children 12 years and under. Young children should receive a dose according to biological age: Children under 2 years: 2.5 ml pediatric suspension twice daily. Children 2 to 5 years: One to two pediatric tablets or 2.5 to 5 ml pediatric suspension twice daily. Children 6 to 12 years: Two to four pediatric tablets or 5 to 10 ml pediatric suspension or one adult tablet twice daily. In children this corresponds to an approximate dose of 6 mg trimethoprim/kg body weight/day, plas 30 mg sulfamethoxazole/kg body weight/day, divided into two equal doses. DOSAGE FORMS: SEPTRA TABLETS, each containing 80 mg trimethoprim and 400 mg sulfamethoxazole, and coded WELLCOME Y2B. Bottles of 100 and 500, and unit dose packs of 100. SEPTRA PEDIATRIC SUSPENSION, each teaspoonful 15 ml) containing 40 mg trimethoprim and 200 mg sulfamethoxazole. Bottles of 100 and 400 ml. SEPTRA PEDIATRIC TABLETS, each containing 20 mg trimethoprim and 100 mg sulfamethoxazole, and coded WELLCOME H4B. Bottles of 100. Product monograph available on request

Ltd. Burroughs Welicome Salle, Que. .Trade Mark

W4046

Letter: Esophageal hemorrhage due to pancreatitis.

iSPiiiSi Esophageal hemorrhage pancreatitis ES^W^^^s'^ due to To the editor: Pancreatitis as a cause is exceedingly uncommon but should be consi...
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