This study compared the effects of diet and cimetidine on theophylline metabolism and examined interactions between these effects. Twelve men received a high-protein diet for 15 days and at another time a high-carbohydrate diet also for 15 days. Cimetidine, 800 mg daily at bedtime, was administered on days 10 through 15 of each dietary period. Theophylline metabolism was studied after the administration of a single intravenous 3 mg/kg dose on days 8 and 15 of each dietary period. Changing from a high-protein to a high-carbohydrate diet decreased theophylline clearance by about the same extent (30% +/- 10%) as treatment with cimetidine (37% +/- 5% during a high-protein diet and 30% +/- 5% during a high-carbohydrate diet). Cimetidine did not significantly influence the effects of diet on theophylline clearance. Conversely, dietary composition did not influence the degree of inhibition of theophylline metabolism induced by cimetidine. Depending on the direction of the change in protein/carbohydrate ratio, the effects of diet and cimetidine treatment were either additive (theophylline clearance was most prolonged during the high-carbohydrate regimen with concurrent cimetidine administration) or counteractive (increasing the dietary protein/carbohydrate ratio at least partially counteracted the inhibitory effect of cimetidine). In individual subjects, effects of cimetidine on theophylline metabolism were somewhat more consistent than diet-induced changes. The results are further evidence that diet and drugs can have similar effects on hepatic drug metabolism rates in humans. Variations in diet over time and individual differences in responses to diet may provide the potential for considerable instability of drug metabolism rates in free-living subjects.(ABSTRACT TRUNCATED AT 250 WORDS)
INTRODUCTION: Situs inversus totalis (SIT) is the complete transposition of the abdominal and thoracic organs. Due to the inherent anatomic differences, patients with situs inversus may pose a unique challenge when undergoing endoscopic procedures because physicians are trained to maneuver the endoscope in a certain manner. CASE DESCRIPTION/METHODS: A 51 year old male presents with a 3 year history of intermittent rectal bleeding. He denies abdominal pain, constipation, and diarrhea. On presentation, physical exam was normal. Although the patient was aware of his diagnosis of SIT at the time of endoscopy, he did not think it was necessary to inform physicians about his condition. In addition, multiple electrocardiograms had been read previously without complications. Laboratory evaluations were normal except for slightly elevated ALT and AST. EGD was performed and showed salmon-colored mucosa in the distal esophagus. Biopsies of the esophagus showed squamous epithelium with acute inflammation and reflux-associated changes, and no evidence of intestinal metaplasia. The stomach was diffusely erythematous and biopsies revealed chronic active gastritis with H. pylori-like organisms. Colonoscopy was normal with the exception of internal hemorrhoids. EGD and colonoscopy were both successfully performed in the standard manner. SIT was discovered during a liver ultrasound performed to further investigate the etiology of his elevated liver function tests. DISCUSSION: Situs inversus totalis may cause additional challenges for endoscopists. One study found that SIT prolonged cecal intubation times. Certain modifications to standard endoscopic technique have been proposed including turning the endoscope 180 degrees clockwise first in the stomach then again in the duodenum, as well as placing the patient in the right lateral decubitus position so that the maneuvers are performed inversely. In our case, the endoscopist was able to successfully navigate the endoscopic procedures without special maneuvers or changes in position and was unaware of the diagnosis of SIT until after the procedure. In conclusion, endoscopies and colonoscopies are feasible in patients with SIT. Various modifications to the endoscopic technique have been suggested, but may not always be required, to safely perform these procedures on patients with SIT.
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