Correspondence
Emergency laparotomy in patients w i t h AIDS Sir I read with interest the article by Davidson and colleagues (Br J Surg 1991 ; 78: 924-6). I must commend the authors on their accumulation of 28 AIDS patients who had undergone emergency laparotomy. There are several important points which need to be clarified. When we reported what remains the largest series of emergency colectomies for cytomegalovirus ileocolitis in AIDS patients, none of the patients had received preoperative anti-HIV therapy such as Zidovudine, anti-CMV therapy such as Foscarnet or Ganciclovir, or antiherpes therapy such as Acyclovir (Dis Colon Rectum 1988; 31: 755-61). This is in strong contradistinction to the series by Davidson and colleagues in which 12 patients received anti-HIV therapy and four patients received antiherpetic therapy. More important, all seven patients with known or suspected CMV infection apparently received anti-CMV therapy before surgical intervention. These differences alone may well account for the differences in mortality rates at one month, which were 71 per cent in our series and 11 per cent in the current Davidson series. However, this difference appears to decrease at 6 months as our mortality rate was 86 per cent whereas the mortality rate in Davidson’s series was 52 per cent. This difference seems much less dramatic. As pointed o u t by Davidson and co-workers, other authors have reported results identical to those of our 1988 study (Ann Surg 1989; 210: 428-33; Arch Surg 1988; 122: 170-5; Dig Dis Sci 1988; 33: 741-50). Therefore, the improved survival reported by Davidson and associates may not be because of earlier surgical intervention or because of a change in our understanding of AIDS. Davidson and colleagues noted that 26 of their patients carried the diagnosis of AIDS before operation. This stands in strong contradistinction to our 1988 paper, in which only three patients were diagnosed before operation as having AIDS. Therefore, the improved survival noted by Davidson can be attributed to an earlier recognition of AIDS and an earlier commencement of medical management. As our medical armamentarium continues to increase and as more and more physicians become familiar with the various protean manifestations of AIDS, our success with the treatment of cytomegalovirus ileocolitis should improve even further.
muscle, then a perforation, and finally the correct diagnosis a simple spasm of the abdominal muscles, that is cramp. The attack had lasted about 15 hours. The pain, at first unbearable, ceased once all the spasm had passed OFT, this spasm relaxing progressively from right to left. A review of text books and the literature and questioning surgical colleagues has not revealed any similar case. Muscle spasm or cramp is a well known condition, rarely affecting abdominal muscles, and the cause is unknown’-’. Cramp does occur in some neurological disorders and metabolic diseases, with certain drugs, and with muscular exertion, but usually there is no such relation. This abdominal cramp was presumably related to unaccustomed exercise, though this was not unduly strenuous and I was not aware of unusual use of the abdominal muscles, only of the quadriceps. There are few exact descriptions of cramp in the literature, probably because the condition is rarely observed by a doctor. Abdominal cramp is described as occurring in heat cramp, the central abdominal muscles going into spasm first, so forming a discrete mass, hefore spreading to all the abdominal muscles; the attack may last 24 hours or longer. However, Talbott in his classic article on heat cramp’, says that attacks of cramp lasting many hours consist of repeated spasms each of a few minutes in duration, not one persistent spasm as in my case. I would be interested to hear from anyone who has knowledge or experience of this condition. -
L. W. Lauste A 4 Marine Guie Marine Drive Brighton BNZ 5TN
UK
1. 2. 3. 4. 5.
Talbott JH. Heat cramps. Medicine 1935; 14: 323--76. Joekes AM. Cramp: a review. J R Soc Med 1982; 75: 546-9. Young JB, David M, George J. Rest cramps in the elderly. J R Coil Ph?sicians Lond 1989; 23: 103-5. Eaton JM. Is this really a muscle cramp? Postgrad Med 1989; 86: 227-32. McGeeSR. Musclecramps. Archlntern Med1990; 150: 51 1-18.
S. D. Wexner Department of Colorecrai Surgery Cleveland Clinic Florida 3000 West Cypress Creek Road Fort Lauderdale Florida 33309 USA
Abdominal cramp Sir Cramp of the abdominal wall muscles is a rare cause of abdominal pain simulating an acute abdomen, so I thought you might be interested to learn of my personal experience. I am a retired surgeon of 82 years and on a recent visit to Central Tibet (September 1990) returned overland to Nepal. I was perfectly well during the two weeks in Tibet but found the last day exhausting as we had to walk/climb down steep rocky paths, because the road was blocked, to the bridge separating Tibet and Nepal. There followed a four-hour jeep ride over a rough road to the mountain resort of Dhulakel (13 716 metres) and a climb up steps, where after a drink of tea I retired to bed. A few minutes after resting on the bed, there was a sudden onset ofexcruciating abdominal pain and I felt a mass in the central abdomen. The very severe pain began to ease an hour or so later, when self-examination revealed not a mass but rigidity of the abdominal wall. The local doctor came, made a cursory examination and gave an intramuscular injection of a strong analgesic drug and left another dose for injection and tablets. About four hours later the abdominal pain had lessened and the whole right abdomen was soft, but the left abdomen remained rigid, the left rectus standing out like an iron bar. Some hours later this rigidity had passed, leaving only the lateral muscles rigid, which felt like a mass. Some 15 hours after the onset all rigidity and pain had gone, leaving the abdomen feeling sore and bruised, and myself weak. My first thought was a ruptured aorta, then a ruptured rectus
92
Surgery for Crohn‘s disease in childhood Sir
We were very interested to read the article by Davies and colleagues ( B r J Surg 1990; 77: 891-4) on surgery for Crohn’s disease in childhood. We were particularly interested in their classification of the site of disease. Most large reviews of Crohn’s disease have divided it into three - ileocolic, small intestinal and colonic’,2. Like Davies and colleagues, we too have just reviewed our results for surgery in Crohn’s disease3. Again like them we noted a significant number of cases (seven of 54) who had more extensive disease, required more operations and had more complications. Five of the seven had relapsed after a mean of 1-4 years and four had had further surgery. These patients were more likely to present with abscesses or fistula formation. In our paper we have termed this group ‘jejuno-ileocolic’, but it is obviously the same group which Davies and colleagues have called ‘panenteric’. The choice of name does not matter: what does is the recognition of this category of Crohn’s patients who appear to be more prone to many of the complications of this disease.
M. A. Stokes G . L. Hill Sl. Vincenl’s Hospital
Elm Park Duhlin 4 Ireland 1.
2. 3.
Goligher JC. Crohn’s disease. In: Goligher JC. ed. Surgery ofrhe Anus, Rectum and Colon. 5th ed. London: Baillibre Tindall, 1984: 971- 1017. Farmer RG. Hawk WA,Turnbull RB. Clinical patterns in Crohn’s disease: a statistical study of 615 cases. Gasf>oenrerolog.p 1975; 68: 627-35. Stokes MA, Hill GL. One hundred operations for Crohn’s disease. Aust N Z J Surg 1990; 60: 677-82.
Br. J. S u r g . . Vol. 79, N o . 1, January1992
Emergency laparotomy in patients w i t h AIDS Sir I read with interest the article by Davidson and colleagues (Br J Surg 1991 ; 78: 924-6). I must commend the authors on their accumulation of 28 AIDS patients who had undergone emergency laparotomy. There are several important points which need to be clarified. When we reported what remains the largest series of emergency colectomies for cytomegalovirus ileocolitis in AIDS patients, none of the patients had received preoperative anti-HIV therapy such as Zidovudine, anti-CMV therapy such as Foscarnet or Ganciclovir, or antiherpes therapy such as Acyclovir (Dis Colon Rectum 1988; 31: 755-61). This is in strong contradistinction to the series by Davidson and colleagues in which 12 patients received anti-HIV therapy and four patients received antiherpetic therapy. More important, all seven patients with known or suspected CMV infection apparently received anti-CMV therapy before surgical intervention. These differences alone may well account for the differences in mortality rates at one month, which were 71 per cent in our series and 11 per cent in the current Davidson series. However, this difference appears to decrease at 6 months as our mortality rate was 86 per cent whereas the mortality rate in Davidson’s series was 52 per cent. This difference seems much less dramatic. As pointed o u t by Davidson and co-workers, other authors have reported results identical to those of our 1988 study (Ann Surg 1989; 210: 428-33; Arch Surg 1988; 122: 170-5; Dig Dis Sci 1988; 33: 741-50). Therefore, the improved survival reported by Davidson and associates may not be because of earlier surgical intervention or because of a change in our understanding of AIDS. Davidson and colleagues noted that 26 of their patients carried the diagnosis of AIDS before operation. This stands in strong contradistinction to our 1988 paper, in which only three patients were diagnosed before operation as having AIDS. Therefore, the improved survival noted by Davidson can be attributed to an earlier recognition of AIDS and an earlier commencement of medical management. As our medical armamentarium continues to increase and as more and more physicians become familiar with the various protean manifestations of AIDS, our success with the treatment of cytomegalovirus ileocolitis should improve even further.
muscle, then a perforation, and finally the correct diagnosis a simple spasm of the abdominal muscles, that is cramp. The attack had lasted about 15 hours. The pain, at first unbearable, ceased once all the spasm had passed OFT, this spasm relaxing progressively from right to left. A review of text books and the literature and questioning surgical colleagues has not revealed any similar case. Muscle spasm or cramp is a well known condition, rarely affecting abdominal muscles, and the cause is unknown’-’. Cramp does occur in some neurological disorders and metabolic diseases, with certain drugs, and with muscular exertion, but usually there is no such relation. This abdominal cramp was presumably related to unaccustomed exercise, though this was not unduly strenuous and I was not aware of unusual use of the abdominal muscles, only of the quadriceps. There are few exact descriptions of cramp in the literature, probably because the condition is rarely observed by a doctor. Abdominal cramp is described as occurring in heat cramp, the central abdominal muscles going into spasm first, so forming a discrete mass, hefore spreading to all the abdominal muscles; the attack may last 24 hours or longer. However, Talbott in his classic article on heat cramp’, says that attacks of cramp lasting many hours consist of repeated spasms each of a few minutes in duration, not one persistent spasm as in my case. I would be interested to hear from anyone who has knowledge or experience of this condition. -
L. W. Lauste A 4 Marine Guie Marine Drive Brighton BNZ 5TN
UK
1. 2. 3. 4. 5.
Talbott JH. Heat cramps. Medicine 1935; 14: 323--76. Joekes AM. Cramp: a review. J R Soc Med 1982; 75: 546-9. Young JB, David M, George J. Rest cramps in the elderly. J R Coil Ph?sicians Lond 1989; 23: 103-5. Eaton JM. Is this really a muscle cramp? Postgrad Med 1989; 86: 227-32. McGeeSR. Musclecramps. Archlntern Med1990; 150: 51 1-18.
S. D. Wexner Department of Colorecrai Surgery Cleveland Clinic Florida 3000 West Cypress Creek Road Fort Lauderdale Florida 33309 USA
Abdominal cramp Sir Cramp of the abdominal wall muscles is a rare cause of abdominal pain simulating an acute abdomen, so I thought you might be interested to learn of my personal experience. I am a retired surgeon of 82 years and on a recent visit to Central Tibet (September 1990) returned overland to Nepal. I was perfectly well during the two weeks in Tibet but found the last day exhausting as we had to walk/climb down steep rocky paths, because the road was blocked, to the bridge separating Tibet and Nepal. There followed a four-hour jeep ride over a rough road to the mountain resort of Dhulakel (13 716 metres) and a climb up steps, where after a drink of tea I retired to bed. A few minutes after resting on the bed, there was a sudden onset ofexcruciating abdominal pain and I felt a mass in the central abdomen. The very severe pain began to ease an hour or so later, when self-examination revealed not a mass but rigidity of the abdominal wall. The local doctor came, made a cursory examination and gave an intramuscular injection of a strong analgesic drug and left another dose for injection and tablets. About four hours later the abdominal pain had lessened and the whole right abdomen was soft, but the left abdomen remained rigid, the left rectus standing out like an iron bar. Some hours later this rigidity had passed, leaving only the lateral muscles rigid, which felt like a mass. Some 15 hours after the onset all rigidity and pain had gone, leaving the abdomen feeling sore and bruised, and myself weak. My first thought was a ruptured aorta, then a ruptured rectus
92
Surgery for Crohn‘s disease in childhood Sir
We were very interested to read the article by Davies and colleagues ( B r J Surg 1990; 77: 891-4) on surgery for Crohn’s disease in childhood. We were particularly interested in their classification of the site of disease. Most large reviews of Crohn’s disease have divided it into three - ileocolic, small intestinal and colonic’,2. Like Davies and colleagues, we too have just reviewed our results for surgery in Crohn’s disease3. Again like them we noted a significant number of cases (seven of 54) who had more extensive disease, required more operations and had more complications. Five of the seven had relapsed after a mean of 1-4 years and four had had further surgery. These patients were more likely to present with abscesses or fistula formation. In our paper we have termed this group ‘jejuno-ileocolic’, but it is obviously the same group which Davies and colleagues have called ‘panenteric’. The choice of name does not matter: what does is the recognition of this category of Crohn’s patients who appear to be more prone to many of the complications of this disease.
M. A. Stokes G . L. Hill Sl. Vincenl’s Hospital
Elm Park Duhlin 4 Ireland 1.
2. 3.
Goligher JC. Crohn’s disease. In: Goligher JC. ed. Surgery ofrhe Anus, Rectum and Colon. 5th ed. London: Baillibre Tindall, 1984: 971- 1017. Farmer RG. Hawk WA,Turnbull RB. Clinical patterns in Crohn’s disease: a statistical study of 615 cases. Gasf>oenrerolog.p 1975; 68: 627-35. Stokes MA, Hill GL. One hundred operations for Crohn’s disease. Aust N Z J Surg 1990; 60: 677-82.
Br. J. S u r g . . Vol. 79, N o . 1, January1992
