Repeat endoscopic biliary sphincterotomy: indications and complications

Endoscopic biliary sphincterotomy [EBS] carries a substantial risk of recurrent choledocholithiasis but retreatment with endoscopic retrograde cholangiopancreatography [ERCP] and repeat EBS is safe and feasible. However, long term results of repeat ERCP and EBS and risk factors for late complications are largely unknown. The aim of this study was to investigate indications and early complications after repeat EBS compared to patients with initial EBS, as well as the long term outcome of repeat ERCP with or without EBS for recurrent bile duct stones. Risk factors predicting late choledochal complications will be identified. Two groups of patients were included. The first group included 28 patients underwent repeat ERCP combined with EBS in 24 for post-EBS recurrent choledocholithiasis. The second group included 25 patients with symptoms of biliary obstruction and underwent ERCP and initial EBS. Early complications were compared for both groups. Patients in group I were followed for long term outcomes of repeat ERCP and EBS were assessed by multivariate analysis. Complete stone clearance was achieved in all patients in both groups. 16 patients in group 1 had no visible evidence of prior sphincterotomy. Early complications occurred in 3 patients in group I and 4 patients in group II. During a follow up period of 0.9 - 2.3 years [mean 1.4 yrs.] for patients in group I, 8 of them [28.5%] developed late complications including stone recurrence [5 patients], acute acalculous cholangitis [2 patients], and acute cholecystitis [1 patient]. There were no deaths attributable to biliary disease. Multivariate analysis identified three independent risk factors for choledochal complications: interval between initial EBS and repeat ERCP and EBS /= 15 mm., and periampullary diverticulum. Choledochal complications were successfully treated with repeat ERCP with or without EBS in 4 patients. Repeat EBS is a safe and effective procedure to manage recurrent biliary and pancreatic complications after initial EBS. The commonest early indications in our study included bleeding at the time of initial EBS, small length of EBS and failure to continue the procedure due to cholangitis, and multiple stones with variable sizes with inability to clear the bile ducts through the initial EBS. Late indications were mainly due to suspected recurrent bile duct stones as indicated by upper right quadrant abdominal pain with elevation of cholestatic enzymes or jaundice, cholangitis, and bile duct lithiasis and dilation proved by ultrasonography. Tight stenosis of biliary orifice which is one of the indications of repeat EBS was not found in our patients. Early complications of repeat EBS are less than initial one. However late choledochal complications after repeat EBS are relatively frequent but are endoscopically manageable. Careful follow up is necessary, particularly for patients with dilated bile ducts, periampullary diverticulum, or early recurrence. Repeat ERCP with or without EBS is a reasonable treatment even for recurrent choledocholithiasis after initial EBS

Effect of a mucolytic agent on gastric secretory functions

To explore the effects of carbocysteine drug, a mucolytic one, on the secretory functions of stomach, this study was carried out on 20 adult persons of both sexes aged between 25-50 years. All persons were subjected to the determination of free and total acidity, mucin content and peptic activity in their fasting gastric juice samples taken before and after two weeks of carbocysteine administration. The results revealed that there is a significant decrease of total gastric acidity, while the free acidity was nonsignificantly decreased. However, the mucin content and the peptic activity were nonsignificantly increased. Also, there was a significant inverse correlation between the mucin content and both of free and total acidity. It was concluded that carbocysteine does not affect the gastric secretory functions and may have a beneficial effect on the gastric mucosa as it helps tissue repair

Study of the role of diet in peptic ulcer disease

The incidence of peptic ulcer is increasing in certain areas of the world, while decreasing in others. This indicates the exposure to environmental ulcerogens or deficiencies of anti-ulcerogenic factors. Diet is considered as one of the environmental ulcerogens, while the others include bacteria and chemical ulcerogens. Fifty patients with peptic ulcer have been studied in a controlled manner to evaluate the role played by the diet in the occurrence of peptic ulcer disease. Results revealed that diet has a role in the development of peptic ulcer disease. For this, an eye should be kept on those ulcerogenic and protective dietary factors such as the number and regularity of meals, state of mastication, time of dinner, refined carbohydrate, animal fat, amount of fiber intake, excess frequent use of spices, salt and salted foods, drugs especially steroidal and non- steroidal, anti-inflammatory drugs, caffeine containing beverages [coffee, tea, cola] and others as milk and liquorice

effect of beta-blocking agent on Q-T interval during acute myocardial infarction

Twenty patients with acute transmural myocardial infarction without complication were selected for this study. An ECG was done daily for ten successive days for the measurement of the Q-T and Q-T intervals. Patients were classified into two groups: Group 1 [10 patients] did not receive beta-blocking agent and group 2 [10 patients] received beta-blocking agent propranolol 40 mg twice daily. The results showed that Q-T interval prolongation occurs in the first few days in group 1, while in group 2 the prolongation of Q-T interval was not statistically significant. The explanations were discussed

Autonomic neuropathy in hyperthyroidism

In this work 15 thyrotoxic patients as well as 15 healthy control subjects were selected to study the integrity of the autonomic nervous system. The tests applied in this study to demonstrate manifestations of autonomic neuropathy were basal heart rate, heart rate response to valsalva maneuver, to deep breathing, to standing as well as blood pressure response to standing, beside performing the facial sweating test. The results showed significant difference between thyrotoxic patients and the control cases as regards the basal heart rate and heart rate response to deep breathing. Insignificant results were obtained in thyrotoxic patients as compared to control subjects while performing valsalva maneuver, heart rate and blood pressure response to standing. Equivocal results were obtained, while performing the facial sweating test

achilles reflex in chronic renal failure

Thirty patients suffering from evidenced chronic renal failure, in addition to ten healthy volunteers were chosen for the measurement of the Achilles reflex time with an electromagnetic kinemometer. Prolongation of the whole reflex time [S-P interval], S-V interval and the V-P interval were detected. Derangement of the nerve function had been suggested to be responsible for the presence of prolonged S-V interval. Prolongation of the V-P interval explained by the presence of myopathy, hyperpotassaemia acidosis and/or the presence of carbohydrate intolerance in chronic renal failure

Plasma and ascitic fluid osmotic pressure in relation to ascites formation

Twenty five schistosomal patients including twenty ascitic and five non ascitic patients have been studied for plasma and ascitic fluid osmotic pressure using the advanced osmometer model 3 L and total proteins were estimated. Ten healthy persons of matched age served as control. We found lower osmotic pressure of plasma in ascitic cases compared to the non ascitic and control group, but we could not find a critical level of osmotic pressure below which ascites occurs

Testosterone assay before and after hemodialysis in chronic renal failure

Estimation of plasma testosterone with radioimmunoassay technique was done in eleven patients suffering from chronic renal failure both before and after the performance of haemodialysis. Low testosterone level was found before the dialysis while normal level was detected after the performance of the dialysis. Hypotestosteronemia could partly explain the presence of impotence, while normal level after the dialysis indicates the participation of other parameters. Diminished response of the Leydig cells to produce testosterone in chronic renal failure is suggested as a sequels of the effect of the uremic toxins

Vascular reactivity in acromegaly

Vascular reactivity was estimated in both ten acromegalic patients and ten controls. The peripheral blood flow was measured by a venous occlusive plethysmography technique. Increased vascular reactivity in acromegalic patients was observed. This may be considered in the explanation of pathogenesis of hypertension in this disease. The probable mechanisms were discussed in the text

effect of thyroid disorders on the healing process in albino rats

Experimental study on the healing process in sixty albino rats subjected to extraction of the central incisor was performed. Three groups were included; control group, T[3] administration group, and hypothyroid state group with neomercazol intake in their diet. Enhancement of the healing process in the second group, conversely delayed healing process in the third group was detected. The explanation were discussed in the text

role of the lung in counter-regulatory hormones in adult-onset diabetes

Glucagon, cortisol and growth hormone were estimated by a radioimmunoassay technique in both the pulmonary artery serum samples after cardiac catheterization and arterial blood serum in seven adult-onset diabetics and ten controls. Hyperglucagonemia had been detected in the diabetic group. The lung in the diabetic group consumed a lesser amount of glucagon and cortisol than that of controls. These findings may be a factor in the pathogenesis of hormonal changes in diabetes mellitus

Serum ascitic fluid cortisol, glucagon and growth hormone in hepatic schistosomiasis

Estimation of cortisol, growth hormone and glucagon had been done in the serum and ascitic fluid of eleven patients presented with hepatic schistosomiasis with ascites. Normal fasting values had been detected in the serum. On the other hand, lower values had been measured in the ascitic fluid. The presence of these hormones in the ascitic fluid should be considered in the treatment of ascites with reinfusion of the ascitic fluid by different methods

effect of some antirheumatic drugs on the ultrastructural and histochemical pattern of guinea pig jejunal mucosa

The effect of acetyl salicylic acid, phenyl butazone and dexamethazone on the ultrastructure and histochemical pattern of guinea pig jejunal mucosa was studied. Electronmicroscopic examination showed atrophy of the microvilli and diminution of the cellular organelles. These changes were mainly manifested with acetyl salicylic acid administration. Succinic dehydrogenase, alkaline and acid phosphatases and non-specific esterase activity was studied. No changes in the activity of the non-specific esterase enzyme were detected, while diminution of the activity of the other three enzymes was more manifested with acetyl salicylic acid administration, and to a lesser extent with phenyl butazone administration. The results were discussed in the text

Serum and ascitic fluid immunoglobulins in advanced hepatic schistosomiasis

Serum and ascitic fluid immunoglobulins and proteins were estimated in twelve patients with hepatic schistosomiasis and moderate ascites. Lower levels were found in the ascitic fluid. Active transport, local formation and passage from intestinal lymphorrhea were suggested as possible etiological underlying mechanisms

Glucagon infusion test in hypothyroidism before and after T[3] therapy

T twenty primary hypothyroid patients and ten control subjects were studied. They were all subjected to: intravenous glucagon infusion test to study the response of their blood glucose. Also I.V. lgucose tolerance test was performed to estimate the glucose disappearance rate [Kg. value]. The same tests were repeated in hypo thyroid patients after triiodothyronine [T[3]] therapy. A supernormal response of blood glucose level was observed in hypothyroid patients before treatment. This finding was attributed to increased tissue glucose utilisation. Decreased secretion and increased glucagon degradation were also suggested. The response to glucagon infusion and the tissue glucose utilisation were normalised after T[3] therapy