Assessment and treatment of choledocholithiasis when endoscopic sphincterotomy is not successful

Background: Choledocholithiasis exists in approximately 15% of patients with gallstones and is present in 3%-10% of those undergoing cholecystectomy

Methods: In this study, we retrospectively analyzed the outcome patients with choledocholithiasis that were managed by open common bile duct [CBD] exploration according to our center's protocol. Endoscopic retrograde cholangiopancreatography [ERCP] was performed for CBD stone clearance. If ERCP and sphincterotomy were not successful, open surgical exploration of CBD was performed with T-tube inser-tion without routine intraoperative cholangiography [IOC]

Results: We studied 1462 patients with choledocholithiasis. ERCP was successful in in 1276 [87.2%] patients. A total of 186 [12.8%] underwent surgery. Of these, 82 [45.2%] had CBD exploration and T-tube insertion without IOC. Choledochoduodenostomy was performed in 82 [44.1%] patients and choledochojejunostomy was performed in 20 [10.8%]. Retained stones were found only in 4 cases which were treated by ERCP

Conclusion: ERCP is successful in most cases with choledocholithiasis. If ERCP fails, open exploration of CBD and T-tube insertion, or biliary-enteric anastomosis are acceptable ways for CBD drainage. The rate of retained stone is not more than expected, thus elective IOC is more acceptable than routine IOC. Routine IOC is time-consuming and particularly difficult in elderly patients and emergency conditions

bulking agent may lead to adrenal insufficiency crisis: a case report

Adrenal insufficiency is a life-threatening disorder which must be treated with glucocorticoid replacement and needs permanent dose adjustment during patient's different somatic situations. Insufficient glucocorticoid doses result in adrenal crisis and must be treated with intravenous hydrocortisone. The patient was known with Adrenal insufficiency and was treated optimally with fludrocortisone and prednisolone since seven years with no history of adrenal crisis. The patient was admitted with abdominal pain, weakness, fatigue and nausea developed 3-4 days after taking psyllium, a bulking agent, prescribed by a surgeon to diagnose anal fissure. Detailed medical history, physical examinations, laboratory and imaging examinations did not approve any other cause of adrenal crisis. Psyllium may interfere with gastrointestinal absorption of prednisolone and/or fludrocortisone and trigger acute adrenal crisis in patients with adrenal insufficiency

Identification of sarcocystis species of slaughtered sheep in Gazvin Ziaran slaughterhouse using PCR-RFLP

Sarcocystosis is caused by species of Sarcocystis, an intracellular protozoan parasite in the phylum Apicomplexa. The intermediate hosts are the herbivores eating infected food or water containing sporocysts excreted by the carnivorous final host, and that results in tissue cysts in corpses. The present study was carried out to identify Sarcosystis species of sheep using PCR-RFLP. In the present study 60 specimens from the diaphragm, heart and esophagus muscles of sheep slaughtered in Qazvin Ziaran slaughterhouse were collected. 40 specimens contained macroscopic Sarcocystis cysts and the next 20 contained microscopic Sarcocystis cysts. They were examined by Dob Smear and digestion method. DNA extraction was carried out by a kit. PCR conditions were optimized for 18S rRNA amplification. Meanwhile, a comparative study was done to investigate the specific primers of the Toxoplasma and Neospora along with the Sarcocystis cases. According to the position of restriction sites, restricted enzymes were selected. Results indicated that the primers were completely unique and specific for detecting Sarcocystis. PCR-RFLP analysis showed that macroscopic cysts and microscopic cysts belonged to Sarcocystis gigantea and Sarcocystis arieticanis, respectively. Sarcocystis species of sheep can be recognized through PCR-RFLP technique using the designed specific primers. By this technique applying TaqI enzyme from microscopic cysts as well as TaqI and HincII enzymes for macroscopic cysts were found more efficient than the others