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Serum bile acids in cholestasis of pregnancy
began t a k i n g the drug. The complaints initially involved the higher intellectual functions (musical performance, m a t h e m a t i cal calculations, j u d g e m e n t ) a n d t h e n progressed to involve speech and motor functions. At no time were the adrenergic signs and symptoms of acute hypoglycemia present. In one case the intellectual deterioration reversed itself upon discontinuation of the drug but in the r e m a i n i n g cases no such improvement occurred. A n extensive search for other possible causes of encephalopathy in these patients was entirely negative. Chronic hypoglycemia induced by oral hypoglycemic agents m a y well be less rare t h a n generally believed and should certainly be considered in all p a t i e n t s on such medicines presenting w i t h any change in mental status or intellectual functioning. (Editor's note," The oral hypoglycemic agents are coming under increasing criticism for their dangerous side-effects; in fact, phenformin has recently been taken off the market. This article stresses a more subtle side-effect t h a n lactic acidosis, b u t a d i s a s t r o u s
one.) Robert Hockberger, MD diabetes mellitus; hypoglycemia, drug induced Life threatening ventricular tachyarrhythmias in delirium tremens. Fisher J, Abrams J, Arch Int Med 137: 1238-1241, (Sep) 1977. A 46-year-old alcoholic patient presented with withdrawal seizures, delirium t r e m e n s a n d low serum potassium a n d magnesium levels. The serum abnormalities were corrected. After the p a t i e n t developed ventricular tachycardia progressing to ventricular fibrillation, lidocaine was given and Pronestyl (procainamide hydrochloride) 250 mg orally every six hours was started. An additional episode of ventricular tachycardia then occurred requiring resuscitation. There were no previously documented neurologic, cardiac or hepatic a b n o r m a l i t i e s . Arrhythmogenic factors associated with delirium tremens include hypokalemia, alcohol and metabolites, hypomagnesemia, acidbase abnormalities and catecholamine excess, with hypokalemia the most p r o m i n e n t cause. Hypokalemia may be due to direct effects of alcohol, i n a d e q u a t e p o t a s s i u m intake, v o m i t i n g , diarrhea, respiratory alkalosis, secondary hyperaldosteronism and r e n a l t u b u l a r acidosis. O t h e r factors c o n t r i b u t i n g to mortality in d e l i r i u m t r e m e n s are fat embolism, a s s o c i a t e d illnesses, dehydration, heat stroke, paraldehyde overdose and hypovolemia. The authors feel t h a t delirium tremens presents so significant a risk of fatal a r r h y t h m i a s t h a t the patient should be monitored, especially if potassium or magnesium stores are low. (Editor's note: Cardiovascular collapse for various reasons is the major cause o f death in delirium tremens, a highly lethal illness frequently underestimated a n d underdiagnosed. Many alcoholic patients develop a hypokalemic alkalosis before they develop the full-blown syndrome o f delirium tremens. A s potassium alone will not correct the metabolic impairment, neither will saline alone.) Thomas Graber, MD
de/irium tremens; tachyarrhythmia Serum bile acids in cholestasis of pregnancy. Laatikainen T, Ikonen E, Obstet Gynecol 50:313-318, (Sep) 1977. Cholestasis of pregnancy is characterized by impaired biliary excretion of bile acids, resulting in the accumulation of these substances in the blood. H a r m to the fetus, with signs of fetal distress, is directly related to the magnitude of cholestasis. The disorder is associated with m a t e r n a l pruritus, which is often the presenting feature. Initial screening tests t h a t most reliably reflect the presence and severity of the condition are the serum glutamic oxaloacetic t r a n s a m i n a s e (SGOT) and serum glutamic pyruvic t r a n s a m i n a s e (SGPT), both of which become elevated. M e a s u r e m e n t s of t o t a l b i l i r u b i n a n d s e r u m a l k a l i n e phosPhatase are considerably less helpful. Cholestasis of pregnancy should be considered in any p r e g n a n t woman who presents with a complaint of pruritus. Liver function tests should be drawn and, if the t r a n s a m i n a s e levels are elevated, the p r e g n a n c y should be r e g a r d e d as high-risk, w i t h careful a n d f r e q u e n t follow-up mandatory. (Editor's note: Gall bladder disease during
7:1 (Jan)1978
pregnancy has been appreciated for years as a real problem. Less well known are the bad effects on the fetus. Two lives must be monitored in the pregnant female.) Jeffrey S. Menkes, MD
cholestasis, pregnancy, pruritus Arteriographic evidence of coronary arterial spasm in acute myocardial infarction. Oliva PB, Breckinridge JC, Circulation 56:366-374, (Sep) 1977. Coronary a r t e r i a l spasm was demonstrated in 6 of 15 (40%) acute myocardial infarctions in patients with coronary artery disease. Spasm was detected by arteriography of the coronary artery judged to be acutely occluded based upon the distribution of ST segment changes on the electrocardiogram (EKG). Spasm always occurred at the site of a n atherosclerotic obstruction and was always separated from the catheter tip by several centimeters. After d e m o n s t r a t i o n of spasm on two arteriograms, intracoronary nitroglycerin (NTG) was administered with subsequent demonstration of vessel patency or more rapid and complete distal vessel filling with a persistent, severe, fixed obstruction. In one patient, at the time of NTG administration and subsequent restoration of blood flow to the distal right coronary artery and AV nodal artery, t h e r e was a m a r k e d reduction in the degree of ST segment elevation and a change in r h y t h m from complete h e a r t block w i t h j u n c t i o n a l p a c e m a k e r to s i n u s tachycardia. This represents a form of limited myocardial reperfusion which may be beneficial. In two patients who were maintained on isosorbide dinitrate (5 mg every 2 hours) and heparin for three days, repeat arteriogram showed continued patency of the originally occluded artery. Spasm of a subtotally occluded atherosclerotic coronary artery may produce complete occlusion with subsequent infarction and thrombosis, or spasm may be a secondary occurrence in response to a stimulus such as increased catecholamines from t r a n s i e n t sympathetic discharge or release of vasoactive substances from platelet aggregates a t the site of a n atherosclerotic plaque. The importance of coronary arterial spasm in the pathogenesis of acute myocardial infarction and whether relief of such spasm is beneficial to ischemic myocardium has not yet been determined. (Editor's note: There is increasing evidence that many cases o f sudden death as well as E K G and enzyme proven myocardial infarction may be due to coronary artery spasm. Many paramedic units are administering N T G to chest pain patients although some caution must be used since an occasional p a t i e n t w i l l develop h y p o t e n s i o n f r o m nitrates.) Jeffrey B. Dubnow, MD
myocardial infarction, arterial spasm; arteriography Mallory-Weiss syndrome. Todd GJ, Zikria BA, Ann Surg 186: 146-148, (Aug) 1977. Sixteen p a t i e n t s w i t h 18 episodes of upper g a s t r o i n t e s t i n a l (UGI) bleeding diagnosed as h a v i n g Mallory-Weiss syndrome were reviewed, as was the literature. Recently, Mallory-Weiss syndrome has been 'diagnosed more frequently due to the use of fiberoptic endoscopy. Excessive alcohol consumption and vomiting continue to be correlated to etiology. However, development of high intraesophagogastric pressures by other means, such as b l u n t abdominal trauma, coughing and heavy lii~ing have been reported. Cases associated with alcohol intake have decreased in more recent studies to 60% of the total. Medical m a n a g e m e n t is the indicated therapy unless t h e r e is massive bleeding. Of recent cases reported, 72% were treated medically with 97% survival. The final conclusion is t h a t all cases of UGI bleeding should be examined by endoscopy and if Mallory-Weiss syndrome is diagnosed, medical m a n a g e m e n t is indicated unless massive bleeding occurs. (Editor's note: A second indication for surgery is mediastinal sepsis. It is intriguing to speculate on why this complication o f esophageal perforation did not develop. It is not always possible to detect the full extent o f perforation via endoscopy thus ideal management should include surgical consultation. I t is interesting that 40% o f these cases were not related to alcoholism.)
Albert Yee, MD
Mallory-Weiss syndrome; gastrointestinal bleeding
JACEP
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one.) Robert Hockberger, MD diabetes mellitus; hypoglycemia, drug induced Life threatening ventricular tachyarrhythmias in delirium tremens. Fisher J, Abrams J, Arch Int Med 137: 1238-1241, (Sep) 1977. A 46-year-old alcoholic patient presented with withdrawal seizures, delirium t r e m e n s a n d low serum potassium a n d magnesium levels. The serum abnormalities were corrected. After the p a t i e n t developed ventricular tachycardia progressing to ventricular fibrillation, lidocaine was given and Pronestyl (procainamide hydrochloride) 250 mg orally every six hours was started. An additional episode of ventricular tachycardia then occurred requiring resuscitation. There were no previously documented neurologic, cardiac or hepatic a b n o r m a l i t i e s . Arrhythmogenic factors associated with delirium tremens include hypokalemia, alcohol and metabolites, hypomagnesemia, acidbase abnormalities and catecholamine excess, with hypokalemia the most p r o m i n e n t cause. Hypokalemia may be due to direct effects of alcohol, i n a d e q u a t e p o t a s s i u m intake, v o m i t i n g , diarrhea, respiratory alkalosis, secondary hyperaldosteronism and r e n a l t u b u l a r acidosis. O t h e r factors c o n t r i b u t i n g to mortality in d e l i r i u m t r e m e n s are fat embolism, a s s o c i a t e d illnesses, dehydration, heat stroke, paraldehyde overdose and hypovolemia. The authors feel t h a t delirium tremens presents so significant a risk of fatal a r r h y t h m i a s t h a t the patient should be monitored, especially if potassium or magnesium stores are low. (Editor's note: Cardiovascular collapse for various reasons is the major cause o f death in delirium tremens, a highly lethal illness frequently underestimated a n d underdiagnosed. Many alcoholic patients develop a hypokalemic alkalosis before they develop the full-blown syndrome o f delirium tremens. A s potassium alone will not correct the metabolic impairment, neither will saline alone.) Thomas Graber, MD
de/irium tremens; tachyarrhythmia Serum bile acids in cholestasis of pregnancy. Laatikainen T, Ikonen E, Obstet Gynecol 50:313-318, (Sep) 1977. Cholestasis of pregnancy is characterized by impaired biliary excretion of bile acids, resulting in the accumulation of these substances in the blood. H a r m to the fetus, with signs of fetal distress, is directly related to the magnitude of cholestasis. The disorder is associated with m a t e r n a l pruritus, which is often the presenting feature. Initial screening tests t h a t most reliably reflect the presence and severity of the condition are the serum glutamic oxaloacetic t r a n s a m i n a s e (SGOT) and serum glutamic pyruvic t r a n s a m i n a s e (SGPT), both of which become elevated. M e a s u r e m e n t s of t o t a l b i l i r u b i n a n d s e r u m a l k a l i n e phosPhatase are considerably less helpful. Cholestasis of pregnancy should be considered in any p r e g n a n t woman who presents with a complaint of pruritus. Liver function tests should be drawn and, if the t r a n s a m i n a s e levels are elevated, the p r e g n a n c y should be r e g a r d e d as high-risk, w i t h careful a n d f r e q u e n t follow-up mandatory. (Editor's note: Gall bladder disease during
7:1 (Jan)1978
pregnancy has been appreciated for years as a real problem. Less well known are the bad effects on the fetus. Two lives must be monitored in the pregnant female.) Jeffrey S. Menkes, MD
cholestasis, pregnancy, pruritus Arteriographic evidence of coronary arterial spasm in acute myocardial infarction. Oliva PB, Breckinridge JC, Circulation 56:366-374, (Sep) 1977. Coronary a r t e r i a l spasm was demonstrated in 6 of 15 (40%) acute myocardial infarctions in patients with coronary artery disease. Spasm was detected by arteriography of the coronary artery judged to be acutely occluded based upon the distribution of ST segment changes on the electrocardiogram (EKG). Spasm always occurred at the site of a n atherosclerotic obstruction and was always separated from the catheter tip by several centimeters. After d e m o n s t r a t i o n of spasm on two arteriograms, intracoronary nitroglycerin (NTG) was administered with subsequent demonstration of vessel patency or more rapid and complete distal vessel filling with a persistent, severe, fixed obstruction. In one patient, at the time of NTG administration and subsequent restoration of blood flow to the distal right coronary artery and AV nodal artery, t h e r e was a m a r k e d reduction in the degree of ST segment elevation and a change in r h y t h m from complete h e a r t block w i t h j u n c t i o n a l p a c e m a k e r to s i n u s tachycardia. This represents a form of limited myocardial reperfusion which may be beneficial. In two patients who were maintained on isosorbide dinitrate (5 mg every 2 hours) and heparin for three days, repeat arteriogram showed continued patency of the originally occluded artery. Spasm of a subtotally occluded atherosclerotic coronary artery may produce complete occlusion with subsequent infarction and thrombosis, or spasm may be a secondary occurrence in response to a stimulus such as increased catecholamines from t r a n s i e n t sympathetic discharge or release of vasoactive substances from platelet aggregates a t the site of a n atherosclerotic plaque. The importance of coronary arterial spasm in the pathogenesis of acute myocardial infarction and whether relief of such spasm is beneficial to ischemic myocardium has not yet been determined. (Editor's note: There is increasing evidence that many cases o f sudden death as well as E K G and enzyme proven myocardial infarction may be due to coronary artery spasm. Many paramedic units are administering N T G to chest pain patients although some caution must be used since an occasional p a t i e n t w i l l develop h y p o t e n s i o n f r o m nitrates.) Jeffrey B. Dubnow, MD
myocardial infarction, arterial spasm; arteriography Mallory-Weiss syndrome. Todd GJ, Zikria BA, Ann Surg 186: 146-148, (Aug) 1977. Sixteen p a t i e n t s w i t h 18 episodes of upper g a s t r o i n t e s t i n a l (UGI) bleeding diagnosed as h a v i n g Mallory-Weiss syndrome were reviewed, as was the literature. Recently, Mallory-Weiss syndrome has been 'diagnosed more frequently due to the use of fiberoptic endoscopy. Excessive alcohol consumption and vomiting continue to be correlated to etiology. However, development of high intraesophagogastric pressures by other means, such as b l u n t abdominal trauma, coughing and heavy lii~ing have been reported. Cases associated with alcohol intake have decreased in more recent studies to 60% of the total. Medical m a n a g e m e n t is the indicated therapy unless t h e r e is massive bleeding. Of recent cases reported, 72% were treated medically with 97% survival. The final conclusion is t h a t all cases of UGI bleeding should be examined by endoscopy and if Mallory-Weiss syndrome is diagnosed, medical m a n a g e m e n t is indicated unless massive bleeding occurs. (Editor's note: A second indication for surgery is mediastinal sepsis. It is intriguing to speculate on why this complication o f esophageal perforation did not develop. It is not always possible to detect the full extent o f perforation via endoscopy thus ideal management should include surgical consultation. I t is interesting that 40% o f these cases were not related to alcoholism.)
Albert Yee, MD
Mallory-Weiss syndrome; gastrointestinal bleeding
JACEP
39/6~