Nd:YAG laser therapy is an attractive palliative treatment for carcinoma of the esophagus and gastric cardia. Twenty-five patients with these tumors underwent laser therapy over a 2-year period, receiving a total of 52 courses of therapy with 189 treatments. Treatments per course averaged 3.6, with a mean of two courses per patient. Luminal diameter is increased with this method; symptomatic improvement in dysphagia occurred in all patients after one course of therapy. Radiographic improvement also is seen. The complication rate in this series was four (2.1%) of 189 procedures, consisting of one perforation, one tracheoesophageal fistula, one pneumopericardium, and one pneumoperitoneum without leak.

We report 10 carcinomas in 8 patients with regional enteritis. Five of the cancers were in the ileum, 4 in the right colon, and 1 in the rectum. The visualized small bowel cancers appeared as benign strictures in small bowel involved by regional enteritis. Most were poorly differentiated. The colon cancers had a more typical radiographic appearance of malignancy. In some patients with small bowel cancer the malignancy was discovered only on histologic evaluation; the malignant nature of the lesion was not appreciated by radiography or gross examination at surgery.

Emergency combined angiographic and endoscopic Neodymium-YAG laser treatment is described in an elderly patient with massive hemorrhage from the afferent limb stump of a Billroth II anastomosis after surgical resection of a gastric carcinoma. In patients with bleeding lesions, who are not operative candidates, such an approach can be life-saving.

Massive secretory diarrhea is associated with some villous adenomas. The mechanism of this secretion is unknown but the character of the diarrhea resembles that of cyclic nucleotide-mediated diarrheas. We have compared the cyclic nucleotide metabolism of a large secretory villous adenoma with a nonsecretory villous adenoma, a solid carcinoma and their normal mucosae. The adenylate cyclase, cyclic AMP content, and a cyclic AMP-dependent protein kinase ratios in the secretory tumor were increased as compared to these values in the nonsecretory tumors and normal mucosae, a situation similar to that seen with cholera toxin-induced diarrhea. Our data suggest that the massive diarrhea in our patient with a secretory villous adenoma may be related to increased adenylate cyclase activity.

• A prospective study of 12 patients with the diagnosis of polymyositis or dermatomyosiois was initiated to determine the characteristics of the esophageal manometric patterns in this group. All of the patients were women between the ages of 30 to 80 years and met three of four of Bohan's diagnostic criteria for these diseases. The patients' conditions were classified according to Rose and Walton's muscle weakness index. Almost two thirds of our patients exhibited distal esophageal dysfunction by manometry. Based on our roentgenographic and manometric data, we conclude that in addition to the well-described abnormalities in the striated portion of the esophagus, smooth-muscle dysfunction occurs with a high frequency in this patient population. (Arch Intern Med1983;143:2262-2264)

A 60-year-old woman presented with recurrent ileostomal hemorrhage 29 years after proctocolectomy for ulcerative colitis. Ileal varices were demonstrated by selective mesenteric angiography, and a portasystemic shunt was performed with control of the bleeding. Stomal varices typically present with repeated episodes of bleeding at and proximal to the mucocutaneous junction of the ileal stoma and attempts at local corrective measures generally meet with only temporary success. A portasystemic shunt to diminish portal hypertension in this situation is currently the most widely accepted therapy for this entity.

REFERENCES 1. REYNOLDS WA, WINKlEMANN RK, SOULE EH: Kaposi's sarcoma: a clinicopathologic study with particular reference to its relationship to the reticuloendotheliac system. Medicine 44:419, 1965 2. Cox FH, HELWIG EB: Kaposi's sarcoma. Cancer 12:289, 1959 3. HANNO R, OWEN LG, CALLEN IP: Kaposi's sarcoma with extensive silent internal involvement. Int J Dermatol 9:718, 1979 4. REED WB, KAMATH M, WEISS L: Kaposi's sarcoma with emphasis on the internal manifestations. Arch Dermatol 110:115,1974 5. DUll W, STOUP AP: Kaposi's sarcoma in infants and children. Cancer 13:684, 1960 6. TEMPLETON AC: Studies in Kaposi's sarcoma. Cancer 30:854, 1972 7. Novls BH, KING H, BANK S: Kaposi's sarcoma presented with diarrhea and protein-losing enteropathy. Gastroenterology 67:996, 1974 8. ROTH lA, SCHEll S, PANZARINO S, CORONARO A: Visceral Kaposi's sarcoma presenting as colitis. Am J Surg Pathol 209, 1978

The present study of metronidazole in perineal Crohn's disease includes 26 patients, and is composed of 17 of 21 patients who were previously reported and 9 additional consecutive patients. The course of these patients was evaluated to determine if the drug could be reduced or stopped, whether or not it continued to be effective for prolonged periods, and what long-term side effects were encountered. Dosage reduction was associated with exacerbation of disease activity in all patients, but in all, the perineal manifestations of disease healed promptly when the full dosage of metronidazole was reinstituted. The drug could be successfully discontinued in only 28% of those in whom cessation was attempted; in those patients whose perineal disease worsened with cessation of therapy, rapid healing was achieved if the drug was reintroduced. Sixteen patients received metronidazole for at least 12 mo including 7 for 18-36 mo. Eight of these 16 patients, including 4 on and 4 off the drug, remain healed; the other 8 patients had advanced healing. The only major side effect observed was paresthesias. These occurred in 50% of the patients and developed in the patients at a mean of 6.5 mo after the onset of treatment. They appeared to be dose related and nonprogressive but tended to persist for prolonged periods even after discontinuance of the drug.

The effect of metronidazole was studied in 21 consecutive patients with chronic unremitting perineal Crohn's disease. Drainage, erythema, and induration diminished dramatically in all patients, and complete healing was obtained in 10 of 18 patients maintained on therapy. Five others have shown advanced healing; in 2 patients the inflammation is improved, but healing is minimal. Side effects of metallic taste, dark urine, and mild gastrointestinal upset occurred in many patients. However, the dosage had to be decreased in only 4 patients and the drug discontinued in 1 patient, all because of peripheral neuropathy that proved to be reversible. In 2 other patients, metronidazole was discontinued because of poor compliance. If further experience corroborates this prompt and striking response in patients with extreme, disabling, and otherwise unmanageable disease, metronidazole will play an important role in the therapy of perineal Crohn's disease.