While bacteremia due to Serratia marcescens is not uncommon, it rarely causes infective endocarditis. We report an isolated case of a 53-year-old male with history of intravenous drug abuse who presented with multiple acute pain symptoms and was found to have S. marcescens bacteremia with septic emboli in his spleen, brain, and testes, secondary to a large aortic vegetation, as well as aortic infective endocarditis with severe aortic regurgitation requiring aortic valve replacement. His course of disease was further complicated by epidural and psoas abscesses and a necrotic testicle requiring orchiectomy due to his ongoing intravenous drug abuse. This case is an atypical presentation of S. marcescens infection, as he had no overt signs of infection such as fever or significant leukocytosis that are typical of bacteremia, and it also highlights the severity and complicated nature of S. marcescens-infective endocarditis.
Background Gastric emptying scintigraphy (GES) reports percent retention at 1, 2, and 4 h. Time to empty half the meal (T½) could simplify GE reporting. Aims To compare the performance of GES T½ to 1‐, 2‐, and 4‐h retention. Methods GES studies were reviewed; results determined according to retention at 1, 2, and 4 h. T½ was determined using 3 methods: (1) GES curve fitting using 0, 0.5, 1, 2, 3, and 4 h data; (2) linear interpolation using 0, 0.5, 1, 2, 3, and 4 h data; and (3) linear interpolation using only 0, 1, 2, and 4 h data. Results Of 495 patients, 265 had normal GE, 4 rapid GE (<30% retention at 1 h), and 226 delayed GE: 17 delayed only at 2 h (>60% ret); 94 delayed only at 4 h (>10% ret); and 115 delayed at both 2 h and 4 h. Strong correlations were seen between each T½ method and 1, 2, 3, and 4 h %‐empty values: curve‐fit T½ (r = −0.851, −0.942, −0.864, −0.744), linear T½ using all imaging times (r = −0.848, −0.972, −0.878, −0.763), and linear T½ using standard imaging times (r = −0.853, −0.974, −0.868, −0.760). The 132 min cutoff for delayed GE captures 99.1% to 100% of delayed GE at both 2 h and 4 h, 76.5% to 94.1% delayed at 2 h only, but only 36.7% to 39.4% delayed at 4 h only; 3.5 to 11.3% of patients with normal GE miscategorized as delayed. Conclusions GES T½ correlates more strongly with retention at 2 h than at 4 h. T½ alone may misclassify patients, particularly those with late‐phase (4 h only) delays, reducing its utility for diagnosing gastroparesis.
Patients with chronic constipation who do not respond to initial treatments often need further evaluation for dyssynergic defecation (DD) and slow transit constipation (STC). The aims of this study are to characterize the prevalence of DD and STC in patients referred to a motility center with chronic constipation and correlate diagnoses of DD and STC to patient demographics, medical history, and symptoms. High-resolution ARM (HR-ARM), balloon expulsion testing (BET) and whole gut transit scintigraphy (WGTS) of consecutive patients with chronic constipation were reviewed. Patients completed questionnaires describing their medical history and symptoms at the time of testing. A total of 230 patients completed HR-ARM, BET, and WGTS. Fifty (22%) patients had DD, and 127 (55%) patients had STC. Thirty patients (13%) had both DD and STC. There were no symptoms that were suggestive of STC vs. DD; however, patients with STC and DD reported more severe constipation than patients with normal transit and anorectal function. Patients with chronic constipation often need evaluation for both DD and STC to better understand their pathophysiology of symptoms and help direct treatment.
Acquired adult-onset zinc deficiency is occasionally reported in patients with malnutrition states, such as alcoholism, or malabsorptive states, such as post-bariatric surgery. The defining symptoms of hypozincemia include a classic triad of necrolytic dermatitis, diffuse alopecia, and diarrhea. We report a case of zinc deficiency in a 39-year-old man with history of gastric bypass surgery and alcoholism. For this patient, severe hypozincemia confirmed acrodermatitis, and zinc supplementation was met with gradual improvement.
Purpose of reviewEsophagogastric junction outflow obstruction (EGJOO), defined as elevated integrated residual pressure (IRP) with preservation of esophageal peristalsis, is a common finding on high-resolution esophageal manometry.Recent findingsThe recent Chicago classification version 4.0 proposes changes to the criteria for diagnosing EGJOO, making this diagnosis more restrictive to now include elevated IRP in both supine and upright positions (with preservation of esophageal peristalsis), presence of obstructive symptoms, and confirmatory tests for EGJOO, such as timed barium esophagram with barium tablet or functional lumen imaging probe.SummaryOnce the diagnosis of EGJOO is established, secondary causes need to be ruled out, especially the use of opioid medications. Upper endoscopy is needed for evaluation of EGJOO patients, though cross-sectional imaging is usually not necessary. Many patients improve without intervention; thus, expectant management is recommended for patients with mild or atypical symptoms. There seems to be a limited role for medical treatment. Botox injection into the lower esophageal sphincter is often used to see if the patient improves before committing to more definitive treatments, such as pneumatic dilation, peroral endoscopic myotomy, or Heller myotomy.
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