110 in the lung, which did not change after the injections. She was in good general condition, but the neurological symptoms progressed to complete paralysis. Only five months after B.C.G. therapy the lung metastases progressed. She was treated then with dimethyl triazeno imidazole carboxamide (D.T.l.c.) and a nitrosourea (B.C.N.U.) with no objective result. Although such neurological conditions as peripheral neuropathy are known complications in patients with malignant lung lesions, we think the development of typical Guillain-Barré syndrome after B.C.G. immunotherapy, with no other changes in general condition, strongly suggests metastases B.C.G.
ments it is no longer necessary to delay endoscopy until after a barium or ’Gastrografin’ meal and that radiology should be performed only when endoscopy has proved negative. Moreover, it is very advisable that early endoscopy (within 48 hours of overt bleeding) should be accepted as routine for patients with acute bleeding.
Gastrointestinal Unit, Department of Medicine, Ospedale L. Sacco, Via G.B. Grassi 74, 20157 Milan, Italy.
causal relation.
a
St. Laurentius
Hospital, Roermond,
Netherlands.
J. A. M. J. WILS G. J. M. M. VAN GOOL.
EMERGENCY ENDOSCOPY IN
GASTROINTESTINAL BLEEDING SIR,- We should like to comment on the important
by Dr Forrest and his colleagues (Aug. 17, p. 394) the value of emergency endoscopy in gastrointestinal bleeding and to report a limited series of 70 endoscopies we have carried out during the past twelve months. paper
on
The mean age of our patients was 52years (range 19-88); of these, 32 presented with hasmatemesis with or without melaena, and 38 with melasna alone. Early in the series, the timing of examinations was several days after admission (3-7 days), often when a barium meal had already been performed. Latterly, endoscopy has usually been performed within 48 hours. Examinations were all performed in the endoscopy room using a forwardviewing panendoscope (Olympus GIFD), under sedation and local analgesia of the throat. Gastric lavage was used in only 2
patients. As shown in the accompanying table, 39 patients examined within 48 hours of overt bleeding and 31
were
(55-7%) (44-3%)
FINDINGS IN RELATION TO TIME OF ENDOSCOPY AFTER ADMISSION
HYPOKALÆMIA OF BARIUM POISONING SIR,-During the treatment of a severe case of barium intoxication, I was surprised to find that several current toxicological manuals do not mention the importance of potassium administration in this rare poisoning. 1,2 Soluble barium salts are extremely toxic and can cause death within a few hours after ingestion.3 It is less well known, however, that a rapid and severe decrease of serum-potassium 4-7 is a constant finding in acute barium poisoning and seems to explain early death in systolic cardiac arrest.6 In experimental conditions a shift of potassium from extracellular to intracellular compartments was found after the administration of barium.8 A 29-year-old female with no known history of medical or psychiatric disease had taken a large dose of barium chloride (12 g. of barium ion) intending to commit suicide. Sodium sulphate was given perorally (30 g.) and intravenously3 (30 g.) to precipitate barium. Therapeutically 200 meq. of potassium was infused intravenously over eight hours. In the same period serum-potassium fell from 2-0 to 1-6 meq. per 1. and later rose to 1-8 meq. per 1. A simultaneous renal loss of only 40 meq. of potassium was measured, which seems to exclude a tubular effect of barium as the cause of hypokalaemia. No extrarenal losses of potassium were noticed. After infusion of a further 50 meq. of potassium (a total of 18-6 g. KCl), serum-potassium became normal. A profound respiratory acidosis (pH 7-06) due to paralysis of skeletal muscles involving respirationwas corrected by artificial respiration and infusion of sodium bicarbonate (250 meq. over 8 hours). The patient recovered completely in 48 hours.
that the infusion of potassium at 25 meq. per sufficient to balance the potassium-displacing capacity of absorbed non-precipitated barium in the reported case. On the other hand the laboratory data suggest that an immediate intravenous bolus of potassium of the order of 50-75 meq. be given in cases of severe barium poisoning. Department of Cardiology, Gentofte Hospital, JENS BERNING. Copenhagen, Denmark. It
hour
Lesions were classified as acute bleeding, within 3-7 days. evidence of recent bleeding, or no evidence of bleeding. Our series, in agreement with previous reports,l-4 shows that the diagnosis-rate falls as the period between admission and endoscopy lengthens (92-3% compared with 64.%), this is especially true as for mucosal lesions, which can heal within 48 hours. Lesions of this kind were diagnosed in 7 patients in whom there was a history of recent ingestion of salicylates (3 cases), phenazone (2), indomethacin (1), and gentamycin (1). Radiology and endoscopy were carried out in 42 patients, and in 17 (40-5%) barium-meal examination did not reveal a lesion. Among them, radiology did not detect 4 gastric ulcers, 3 duodenal ulcers, and 2 gastric cancers, and it failed to diagnose all acute mucosal lesions (6 cases). In our series, moreover, additional lesions were seen at endoscopy in 20 patients, and radiology was never able to demonstrate the site of bleeding.
We believe that with modern
forward-viewing instru-
Creek, J. N., Gray, J. W., Nance, F. C., Cohn, I. Ann. Surg. 1972, 175, 771. 2. Allen, H. M., Block, M. A., Schuman, B. M. Archs Surg. 1973, 106, 449. 3. Katon, R. M., Smith, F. W. Gastroenterology, 1973, 65, 728. 4. Cotton, P. B., Rosenberg, M. T., Waldram, R. P. L., Axon, A. T. R. Br. med. J. 1973, ii, 505. 1.
G. BIANCHI PORRO M. PETRILLO.
seems was
FOLLOW-UP IN TUBERCULOSIS
SIR,-Dr Edwards (Dec. 14,
p. 1453) is, of course, quite in his statement that tuberculosis in Britain is a notifiable disease by statute, but his further statement that a patient, once notified, must remain on the chest-clinic register for five years after the disease is deemed to be quiescent does not necessarily follow. Amongst the many documents circulated from the Department of Health and Social Security dealing with the recent reorganisation, there is one—HRC (73) 34, circular 58/73-which summaricorrect
1. The Merck Manual. Rahway, New Jersey, 1972. 2. Dreissach, H. Handbook of Poisoning. Los Altos, California, 1974. 3. Goodman, L. S., Gilman, A. Pharmacological Basis of Therapeutics. New York, 1965. 4. Lewi, Z., Bar-Khayim, Y. Lancet, 1964, ii, 342. 5. Diengott, D., Rozsa, O., Levy, N., Muammar, S. ibid. p. 343. 6. Habicht, W., v. Smekal, P., Etzrodt, H. Med. Welt. 1970, 28, 1292. 7. Gould, D. B., Sorrell, M. R., Lupariello, A. D. Archs intern. Med. 1973, 132, 891. 8. Roza, O., Berman, L. B. J. Pharmac. exp. Ther. 1971, 177, 433.
ments it is no longer necessary to delay endoscopy until after a barium or ’Gastrografin’ meal and that radiology should be performed only when endoscopy has proved negative. Moreover, it is very advisable that early endoscopy (within 48 hours of overt bleeding) should be accepted as routine for patients with acute bleeding.
Gastrointestinal Unit, Department of Medicine, Ospedale L. Sacco, Via G.B. Grassi 74, 20157 Milan, Italy.
causal relation.
a
St. Laurentius
Hospital, Roermond,
Netherlands.
J. A. M. J. WILS G. J. M. M. VAN GOOL.
EMERGENCY ENDOSCOPY IN
GASTROINTESTINAL BLEEDING SIR,- We should like to comment on the important
by Dr Forrest and his colleagues (Aug. 17, p. 394) the value of emergency endoscopy in gastrointestinal bleeding and to report a limited series of 70 endoscopies we have carried out during the past twelve months. paper
on
The mean age of our patients was 52years (range 19-88); of these, 32 presented with hasmatemesis with or without melaena, and 38 with melasna alone. Early in the series, the timing of examinations was several days after admission (3-7 days), often when a barium meal had already been performed. Latterly, endoscopy has usually been performed within 48 hours. Examinations were all performed in the endoscopy room using a forwardviewing panendoscope (Olympus GIFD), under sedation and local analgesia of the throat. Gastric lavage was used in only 2
patients. As shown in the accompanying table, 39 patients examined within 48 hours of overt bleeding and 31
were
(55-7%) (44-3%)
FINDINGS IN RELATION TO TIME OF ENDOSCOPY AFTER ADMISSION
HYPOKALÆMIA OF BARIUM POISONING SIR,-During the treatment of a severe case of barium intoxication, I was surprised to find that several current toxicological manuals do not mention the importance of potassium administration in this rare poisoning. 1,2 Soluble barium salts are extremely toxic and can cause death within a few hours after ingestion.3 It is less well known, however, that a rapid and severe decrease of serum-potassium 4-7 is a constant finding in acute barium poisoning and seems to explain early death in systolic cardiac arrest.6 In experimental conditions a shift of potassium from extracellular to intracellular compartments was found after the administration of barium.8 A 29-year-old female with no known history of medical or psychiatric disease had taken a large dose of barium chloride (12 g. of barium ion) intending to commit suicide. Sodium sulphate was given perorally (30 g.) and intravenously3 (30 g.) to precipitate barium. Therapeutically 200 meq. of potassium was infused intravenously over eight hours. In the same period serum-potassium fell from 2-0 to 1-6 meq. per 1. and later rose to 1-8 meq. per 1. A simultaneous renal loss of only 40 meq. of potassium was measured, which seems to exclude a tubular effect of barium as the cause of hypokalaemia. No extrarenal losses of potassium were noticed. After infusion of a further 50 meq. of potassium (a total of 18-6 g. KCl), serum-potassium became normal. A profound respiratory acidosis (pH 7-06) due to paralysis of skeletal muscles involving respirationwas corrected by artificial respiration and infusion of sodium bicarbonate (250 meq. over 8 hours). The patient recovered completely in 48 hours.
that the infusion of potassium at 25 meq. per sufficient to balance the potassium-displacing capacity of absorbed non-precipitated barium in the reported case. On the other hand the laboratory data suggest that an immediate intravenous bolus of potassium of the order of 50-75 meq. be given in cases of severe barium poisoning. Department of Cardiology, Gentofte Hospital, JENS BERNING. Copenhagen, Denmark. It
hour
Lesions were classified as acute bleeding, within 3-7 days. evidence of recent bleeding, or no evidence of bleeding. Our series, in agreement with previous reports,l-4 shows that the diagnosis-rate falls as the period between admission and endoscopy lengthens (92-3% compared with 64.%), this is especially true as for mucosal lesions, which can heal within 48 hours. Lesions of this kind were diagnosed in 7 patients in whom there was a history of recent ingestion of salicylates (3 cases), phenazone (2), indomethacin (1), and gentamycin (1). Radiology and endoscopy were carried out in 42 patients, and in 17 (40-5%) barium-meal examination did not reveal a lesion. Among them, radiology did not detect 4 gastric ulcers, 3 duodenal ulcers, and 2 gastric cancers, and it failed to diagnose all acute mucosal lesions (6 cases). In our series, moreover, additional lesions were seen at endoscopy in 20 patients, and radiology was never able to demonstrate the site of bleeding.
We believe that with modern
forward-viewing instru-
Creek, J. N., Gray, J. W., Nance, F. C., Cohn, I. Ann. Surg. 1972, 175, 771. 2. Allen, H. M., Block, M. A., Schuman, B. M. Archs Surg. 1973, 106, 449. 3. Katon, R. M., Smith, F. W. Gastroenterology, 1973, 65, 728. 4. Cotton, P. B., Rosenberg, M. T., Waldram, R. P. L., Axon, A. T. R. Br. med. J. 1973, ii, 505. 1.
G. BIANCHI PORRO M. PETRILLO.
seems was
FOLLOW-UP IN TUBERCULOSIS
SIR,-Dr Edwards (Dec. 14,
p. 1453) is, of course, quite in his statement that tuberculosis in Britain is a notifiable disease by statute, but his further statement that a patient, once notified, must remain on the chest-clinic register for five years after the disease is deemed to be quiescent does not necessarily follow. Amongst the many documents circulated from the Department of Health and Social Security dealing with the recent reorganisation, there is one—HRC (73) 34, circular 58/73-which summaricorrect
1. The Merck Manual. Rahway, New Jersey, 1972. 2. Dreissach, H. Handbook of Poisoning. Los Altos, California, 1974. 3. Goodman, L. S., Gilman, A. Pharmacological Basis of Therapeutics. New York, 1965. 4. Lewi, Z., Bar-Khayim, Y. Lancet, 1964, ii, 342. 5. Diengott, D., Rozsa, O., Levy, N., Muammar, S. ibid. p. 343. 6. Habicht, W., v. Smekal, P., Etzrodt, H. Med. Welt. 1970, 28, 1292. 7. Gould, D. B., Sorrell, M. R., Lupariello, A. D. Archs intern. Med. 1973, 132, 891. 8. Roza, O., Berman, L. B. J. Pharmac. exp. Ther. 1971, 177, 433.
