No abstract

Despite well-established antiemetic properties of marijuana, there has been increasing evidence of a paradoxical effect in the gastrointestinal tract and central nervous system, given rise to a new and underrecognized clinical entity called the Cannabinoid Hyperemesis Syndrome. Reported cases in the medical literature have established a series of patients exhibiting a classical triad of symptoms: cyclic vomiting, chronic marijuana use, and compulsive bathing. We present a case of a 29-year-old man whose clinical presentation strongly correlates with cannabinoid hyperemesis syndrome. Despite a diagnosis of exclusion, this syndrome should be considered plausible in the setting of a patient with recurrent intractable vomiting and a strong history of cannabis use as presented in this case.

Background: Clostridium difficile infection (CDI) accounts for significant inhospital mortality. The purpose of this study was to validate a 9-point severity score index (SSI) at the time of diagnosis that could predict severity and mortality in CDI.Methods: Patients with positive toxin A/B were screened and enrolled within 48 hours of diagnosis. They were categorized based on SSI into mild, moderate, or severe disease. The Charlson Comorbidity Index (CCI) was calculated, and the patients were divided into the following categories: CCI 0, 1, Q 2 or greater. All patients were followed for a period of 90 days.Results: Fifty-four male patients were enrolled (mean age, 76.8 years).Mild, moderate, and severe disease was scored in 63%, 30%, and 7% of the patients, respectively. Low albumin (53.7%) and altered white blood cell count (46.3%) were the most common criteria. Need for intensive care unit care was more frequent with higher SSI (P G 0.05). Mortality rate correlated with disease severity (P = 0.005). The CCI score did not correlate with the severity of CDI; nevertheless, a CCI of 2 or greater had a direct association with overall mortality (P = 0.0001).Discussion: Severity score index measured at the time of diagnosis is a useful tool to assess severity and predict mortality. A high SSI score suggests the need for intensive care unit care in patients with CDI. Subsequent studies are needed to assess if SSI at the time of diagnosis should be used to determine the level of care and treatment strategies that may modify outcomes in this population.

Malignant tumors of the small bowel are unusual and account for only 1% to 5% of all gastrointestinal tract malignancies. Thirteen cases of malignant tumors of the small bowel identified at the VAMC in Puerto Rico from January 1999 to September 2001 and a review of the literature are presented. The mean age of our cases was 67 (range: 45-78). Vague abdominal pain, nausea, vomiting, and melena were the most frequently reported symptoms. The average time from first symptoms to diagnosis was 3.2 months. A positive test for occult blood or hypochromic microcytic anemia was invariably present. Hyperbilirubinemia and increased alkaline phosphatase were warning signs that allowed earlier diagnosis in patients with duodenal tumors. Fifty-four percent of the lesions were detected by endoscopic examination while 46% relied on radiographic studies. Eleven had carcinomas and two malignant gastrointestinal stromal tumors. Neither carcinoids nor lymphomas were identified. Our report of thirteen cases of malignant small bowel tumors is unusual and exhibits differences with the previously reported data. The cases were identified in a limited Hispanic population in a short period of time. Aggressive evaluation and a high suspicion of these malignancies should be entertained whenever subtle symptoms and unexplained gastrointestinal blood loss are assessed.

Chronic intestinal pseudo-obstruction is a rare syndrome with high morbidity and mortality. The pathophysiology is not well understood, although it is postulated that it involves some sort of neuropathic and/or myopathic dysfunction resulting in intestinal dysmotility. We present the first case of chronic intestinal pseudo-obstruction secondary to a paraneoplastic syndrome associated with a primary small cell prostate cancer.