Document YG19vRoK7dk278meZbBNkv120

../ . *. 1 ,**5 ., . ''TllELANCET, FEBRUARY22,1986 ` . . :** , . *`.-I#,-- <,,. . ? - fi'iV* ^ ^i} *, , . , f faS*!*!*. i : V- ,/i& :>- ,ii. yv. : ` V.'t.Wfr '.-n-X-'j.r' Letters to'thje Editor ^^r- ;. S * // *'" *>** ' v,; . < * H ` . J ' d. ''-..V':***-' >. jl A __ ......................vT.v^,;................... . ....... .... ' SUCRALFATE AMELIORATES PERIRECTAEPAIN ^ ' DUE TO BILBACID MALABSORPTION 1 : ,, Sir,--One experimental , approach to t/eating hyper- cholestcfolacmia is partial Ileal bypass,1 a surgical procedure that MALIGNANT PLEURAL MESOTHELIOMA FIVE YEARS reduces bile acid reabsorptioiiin the distal ileum. One adverse effect AFTER DOMESTIC EXPOSURE TO BLUE ASBESTOS of this operation is persiatenr rectal pain induced by the bile add . St*,--An association between malignant pleural mesothelioma and asbestos exposure-has been confirmed,1 and the latent period between exposure and emergence ofthe tumour it usually said to be JO-60 years (average 35-40 years).1 *We report a case In which a 28-ycar-oId man presented with advanced pleural mesothelioma, 5 yean after briefdomestic exposure to blue asbestos. We believe this to be the youngest reported case. Although it is recognised that a few cases of maligoant pleural mesothelioma have been recorded without documented evidence ofindustrial asbestos exposure,1 we believe that there is sufficient evidence in this case to suggest that the tumour was initiated by a short period ofdomestic blue asbestos exposure, . , This 28-year-old man presented with a 1-year history of weight loss with 6 months of night sweats and. general malaise. His haemoglobin was 9*2 g/dl, erythrocyte sedimentation 128 mm/h malabsorption- ' ' A man found to.be hyperchoIesteroUcmic' at agc 23 had a myocardial Infarction at the age of 34: Coronary angiography demonstrated 90ft occlusion' of his circumflex anery and 50% occhalon'of his right coronary anery. His persistently raised tool and tow-density-ltpoprotein (LDL) choUsttrol levels were not effectively Towered by several dietary and pharmaceutical interventions, and a partial ileal bypass was performed. In terms of plasma total and LDLcholestcrol concentrations the procedure was effective: . ' ." ' : " ' ' Wanna ' ' flaima dmkxtn>l (mfflfl} trigfyahMt ' ' Tual VLDL `IDL UDL (msW . ': Btrw*(n-) 376J7 i#+9 J06*J3 31+2 187I8 . ' After (n"3) 21118* M+6 1SSI3* 20+2* , 178*48 ^ > Vtlvu timf*nSEM. `Kblifetatb lowtr(pCO'OJ). , js. *' (Westergreo), and a chest X-ray revealed multiple pleural nodules, I as did computerised tomography (see figure).. ' - He had knocked down a wall whilst renovating bis house 5 year* However, after the ileal bypass the patient had intermittent diarrhoea (i or 6 loose stools daily) with severe and persistent anal previously. The wall partition was packed with blue asbestos, and . pain. Despite 8 g cholestynumne at bedtime to bind bile adds - - over a 72 h period he had been heavily exposed to the dust. He had and palliative treatments such as sitz baths, topical lignocaine, . not worn a face mask. " , -suppositories, aluminium hydroxide tablets, and paracetamol, the . . patient continued to complain of aevere pain. During the first 8 postoperative months he was admitted to hospital three times for ` treatment of an anal fissure and abscess. Although increasing ' chalestynmine to 16 g per day and addiAglt^icramide decreased the ' stool frequency, the constant perirectal burning did not subside.' ' This pain and/or the use ofthese medications meant that tire patient .. was unable to carry on normal dally activities, resulting in discord within the family, Before reversing the bypass we decided to try sucralfate. After Only 4 days of sucralfate therapy (2 g every 6 h), the patient's perirectal burning was totally relieved for the first time in nearly 9 months. He reported pain reliefIrrespective'ofthe amount ofdally intermittent diarrhoea. Discontinuing and restarting sucralfate - confirmed this agent was relieving the patient's perirectal pain. Sitz baths and the other medications were no longer needed. During the past 10 months the patient has been able to taper his dose of . sucralfate to 1 or 2 g pet day with symptomatic relief. \ Sucralfate is comparable with cholestyramine in its bile-binding capacity2 and has a high-binding affinity for defective mucosa, v .. Computerised tomograpldc scaa afluag shewing nodules. forming a protective barrier over ulcer sites.1 More than 90% ofan administered close is recovered unchanged in the fleces,4 Thcmost : A pleuropneumonectomy was done, and the tumour was found to have sufficient histological characteristic* to merit a diagnosis of common adverse effect of suctalfite is constipation (Marion Laboratories product information on 'Carafate*). These combined properties led to the successful use of Sucralfate in this patient. ! malignant mesothelioma--namely, focal cellular positivity for cytokeratin, negative immunoperoxidase stain for carrinoembtyonk While a previous case-report describes the successful treatment of choierectic diarrhoea with sucralfate,1 we believe that this is the . antigen, presence ofcytoplasmic tono filaments, and poorly formed microvilli. There are several histological subtypes of mesothelioma;4 this tumour was the mixed type, since It also first evidence that sucralfate is effective In the management of perirectal pain associated with bile acid malabsorption. contained both spindle and pleomorphic cells. The patient died before external beam radiotherapy could be started, and necropsy was not done. ` This case is remarkable for the short history between exposure Qinlcvl Cemex ' io4 MoIkuIk Dbase Bruch,, KitbnpJ Htn, LuftC* tfld Stood lottilute, Mitwoi] iostMuiej of . 94th4fdJt, Mifyluid 1020^ USA JAMBS R. Hunter LinUa McCutLAOH Jeffrey M. Hoeo and tumour presentation and for the briefperiod ofexposure, which was domestic. It highlights the need for extreme care during exposure to dust environments. t>vp*rtroni Canliolhcmcfc &atgetyt LsoJan Hwplul, UodonEI IBB > S. J. Booth E. J. M. Weaver , 1-Mowt RB, SytkVila H, YrCo RL. Tbe tlftcl of parrot Ut*l Bypui on ptajiDi UpopretrlM. Cbtuhikl ISWi IS) 1S9-74. . 2. FUtitr RS. Suer.true rwkwofdnij laltrniliMd ufrtr JCAn G*urmi*il 19SI: J (wppl JJ; Hl-W. , ], Nipiitiiiu X, HloqvTi St>MiV< eutdinc dTuvr#l/Bi is ulctr lesion I: E,perlmeal la' . ' 1. SdiVotT IJ, Chuff J, FC. Xvlitiwu Vctuvtn Hpciure to ubceios and mtwdirtkime. N EiqtJMiJ |MJ,27Z, J40-SS, a. Fts* JR- MetotlftlwM. Br] Woif ,IW 1903, H 521-W. , i. Crctnh'iM, lAOfi Ditia TA_ MeuxhelioilU- Br] Mu MU 1971; Sli 91-104, 4. Ahotr /, WktaiX PH. AtiUfnim mtttltulteme itfWw IVS7-W, Cbai !97Jj Tti . . 434-44, , ;, . fill wits mile kM Iadacl parit ttku mtvtn, saltbelled luciilfke, AiMll9SOjlitO-S), . .. 4, Giruer WN. Sseolfitc illenuilee rtieiepp Af peptic uker dUesw, Gtl* Phttm 1982j ll 307" 14. , . 3. MeoLC.KftaleeDJ.Siicnllht'ltarwfactiolcrec'IciSittSsu.SomliAMjmil ' 74iS. ' . .... , . ' ' ' ' . V "..v, rf., 1! li (' -2