URINARY TRACT INFECTIONS—Problems in Medical Management

The lesion principally responsible for chronic, or recurrent, urinary tract infection is a focus in the interstitial tissue of the kidney. Most cursory antimicrobial therapy suppresses the manifestations of lower urinary tract involvement but does not eradicate the renal focus. In order to cure rather than merely suppress the infection, it is imperative that, as early as possible, steps be taken to isolate and identify the etiologic microorganism and to determine its sensitivity to antimicrobial agents. Based on this information sufficient amounts of drug should be given for an adequate period (probably at least two weeks) to eradicate the infection within the renal tissue. Such a program would tend to reduce the number of cases in which irreversible renal failure develops from chronic pyelonephritis.     

RESISTANT URINARY TRACT INFECTIONS—Combined Autogenous Vaccine and Drug Therapy

The “miracle” antibiotics and sulfa drugs have been found unsatisfactory in treating certain severe resistant urinary tract infections apparently due to lack of immunity factor in the patient. Of a series of 56 patients with resistant urinary tract infection who were treated with autogenous vaccine and then with sulfa drugs, 26 were completely cured.     

COMMON ANORECTAL COMPLICATIONS IN PREGNANCY—Methods of Management

The hormonal, anatomic and pelvic vascular changes of pregnancy have a profound effect on the anorectum, making hemorrhoidal disease the most common anorectal complication of pregnancy. Anal infections such as fissures, abscesses and fistulas are relatively infrequent.Physiologic engorgement of the hemorrhoidal vessels during pregnancy is quite common, transitory and requires only simple palliation. True symptomatic hemorrhoidal disease, however, is less common, more permanent and will usually need corrective treatment to prevent immediate complications and future aggravation. Serious rectal and colonic diagnostic problems demand endoscopic investigation regardless of the pregnancy.Clinical experience and studies seem to indicate that extreme conservatism in the treatment of severe complicated hemorrhoidal disease during pregnancy appears to be unwarranted. After consultation and agreement, surgical treatment of severe, disabling, symptomatic hemorrhoids that are not responsive to palliation can be safely accomplished during the second trimester of pregnancy. Once true hemorrhoidal disease develops, correction should be done before a subsequent pregnancy to avoid later increased aggravation and morbidity.     

THE SIGNIFICANCE OF INFECTION IN ALLERGIC DISEASE—Its Influence on Diagnosis and Management

The presence of infection in allergic disease produces a confused picture in which two different causative factors must be clearly separated by the physician if he is to treat the patient successfully. The effects of infection are not consistent. There are situations, as seen in infectious diseases, where symptoms of allergic disease are temporarily relieved and others where the infection may intensify or precipitate the allergic condition. It is likewise important to recognize the complications superimposed upon allergic disease by infection. In such cases, control of the infection is as dependent upon control of the allergy as it is upon antibiotics.     

POSTOPERATIVE ESOPHAGEAL COMPLICATIONS—Prevention and Treatment

Postoperative esophagitis and stricture formation may be more serious than the disease for which operation was done.The best treatment is prevention by avoiding use of a nasogastric tube if possible. If it has to be used, the tube should have a small lumen and be removed as soon as possible.When surgical operation is necessary, the cardioesophageal junction should not be sacrificed unless it is absolutely necessary to do so.Conservative treatment if begun early can minimize or prevent the development of esophagitis and subsequent stricture formation.     

Upper Gastrointestinal Hemorrhage—Diagnosis and Management

The current management of a patient with upper gastrointestinal hemorrhage involves three steps: initial correction of unstable hemodynamics, obtaining the specific diagnosis of the lesion responsible for gastrointestinal blood loss, and therapy directed at the specific bleeding lesion. The current approach to upper gastrointestinal hemorrhage is carrying out upper gastrointestinal endoscopy following stabilization of the patient. Although improved morbidity and mortality statistics have been slow to appear, the use of endoscopy permits appropriate therapy directed at the specific lesion. Specific therapeutic measures have been outlined for seven common causes of upper gastrointestinal hemorrhage. The advent of therapeutic endoscopy promises to bring further advances in therapy in the near future.