ABSTRACT
Parapapillary and periampullary choledochoduodenal fistulas [CDF] are rare conditions. We here report a case of benign parapapillary choledochoduodenal fistula associated with early ampullary carcinoma [pT1NoMo]. A 54-year-old Jordanian man had recurrent cholangitis without clinical jaundice. He had marked elevation of the alkaline phosphatase [AP] and Gamma Glutamyl Transferase [GTT]. Abdominal ultrasonography showed distension of the gallbladder with dilatation of the common bile duct [CBD]. Duodenoscopy showed a swollen ampulla with no intraduodenal growth. Cannulation the orifice of the papilla of Vater failed. But endoscopic biopsy revealed adenocarcinoma. Magnetic resonance cholangiopancreatiocography showed a dilated bile duct with a filling defect in its most distal part. With the diagnosis of ampullary carcinoma, the patient underwent pylorus-preserving pancreatico-duodenectomy [PPPD]. The gross and microscopic examination of the resected specimen showed a dilated CBD, a small-sized benign choledocho-duodenal fistula to the CBD above the tumor, and a non-dilated pancreatic duct that opened above the tumor. The smallsized fistula was missed by all used diagnostic procedures. This communication presents a unique case of association between ampullary carcinoma with benign small sized parapapillary CDF that caused cholangitis with marked elevation of AP and GTT but without clinical jaundice. The benign CDF may cause cholangitis and together with the high bilio-pancreatic junction may increase the risk of biliary cancer
ABSTRACT
Objective: To evaluate the effects of Mirazid? and myrrh volatile oil on adult Fasciola gigantica (F. gigantica ) under laboratory conditions. Methods: The effects of oleoresin extract of myrrh (Mirazid?) and myrrh volatile oil on the surface morphology of adult F. gigantica following treatment in vitro had been determined by scanning electron microscopy. The results were compared with those observed in the fluke tegument following incubation in triclabendazole sulphoxide (TCBZ-SO), active form, (Fasinex?, Ciba-Geigy). Results: Observations of the efficacy of Mirazid? oleoresin extract and myrrh volatile oil indicated that both products showed dose-dependent anthelmintic efficacy. The anterior half of the fluke was consistently more severely affected than the posterior half. The surface changes induced by Mirazid? oleoresin extract were less severe than those observed after exposure to either myrrh volatile oil or TCBZ-SO. Flukes showed swelling after these treatments, but its level and blebbing were much greater with myrrh volatile oil; in which patches of tegumental sloughing were observed in the apical cone and the posterior mid-body region of flukes. This was not observed after treatment with Mirazid? oleoresin extract. Conclusions: The comparatively more disruption, observed in myrrh volatile oil exposed specimens, compared to that exposed to Mirazid? oleoresin extract might suggest that the anthelmintic activity of Mirazid? oleo resin extract was attributed to its content of volatile oil. So, increasing the concentration of myrrh volatile oil in Mirazid? might possibly help to developing its anthelmintic activity.