Study of gall bladder contractility and prevalence of gallstones in Egyptian patients with liver cirrhosis

Gall bladder stones are considered a public health problem allover the world. Many factors have been proposed to explain the increased incidence of gallstones in liver cirrhosis as alcoholism, changes in total bile acid pool, decreased cholesterol secretion, hemolysis secondary to hypersplenism, increased oestrogen levels and changes in gall bladder and sphincter of Oddi motility, but the exact mechanism has not been yet elicited. Our objective was to study gall bladder contractility and prevalence of gallstones in patients with liver cirrhosis in addition to analysis of the effect of portal hypertension on these two parameters. Eighty patients with chronic liver disease were enrolled [60 patients with liver cirrhosis and 20 patients with pure hepatosplenic schistosomiasis]. Ultrasonographic diagnosis of gallstones with evaluation of gall bladder contractility and portal hypertension were done. An increase in the number of subjects with gallstones with an increase of gall bladder fasting volume and residual volume with a decrease in gall bladder ejection fraction in the patients than the controls. Also there was an increase in the percentage of patients with gallstones among those with higher grades of portal hypertension. Patients with liver cirrhosis have higher frequency of gallstones with diminished gall bladder contractility and higher measures of portal hypertension

Valsartan plus sclerotherapy compared with sclerotherapy alone in cirrhotic patients after variceal bleeding : clinical and haemodynamic randomized trial

Background and Aims: Cirrhotic patients who have bleeding from oesophageal varices are at high risk for rebleeding if no definite therapy to prevent rebleeding has been initiated. Angiotensin II type 1 receptor blockers [ARBs] have been proposed as new drugs for portal hypertension. This randomized prospective clinical trial aimed to assess the efficacy and safety of long-term valsartan [one of ARBs] treatment for prevention of variceal rebleeding in cirrhotic patients when added to endoscopic sclerotherapy [ES] comparing with ES alone and to assess the effect of valsartan on systemic and portal haemodynamics

Methods: Sixty hospitalized Cirrhotic patients [Child A and B with endoscopically proved first episode bleeding oesophageai varices were included into the study. After control of index variceal bleeding, patients were randomized into 2 groups: group I included 30 patients, treated by regular ES every 2 weeks plus valsartan 80 mg once daily orally, and group II included 80 patients, treated by regular ES alone every 2 weeks. All patients were subjected to thorough history taking and full clinical examination beside the following investigations at the start and after 8 weeks [end of the study]: complete blood picture, liver and kidney function tests, K+ and Na+ levels, and hepatic venous pressure gradient [HVPG]. Hepatitis B and C markers. I.H.A for schistosomal affection, abdominal ultrasonography were done only at the start of the study

Results: Initially, the 2 groups of patients were matched for age, sex, aetiology of liver disease, severity of liver disease [Child-Pugh score], biochemical, haematological and endoscopic data at randominzation. At the end of the study, group I had a higher variceal obliteration rate [66.6% vs. 6.7% in group II, P < 0.001] and lower variceal rebleeding [6.7% vs. 40% in group II, P = 0.005]. Portal haemodynamic results showed significant decrease of HVPG in group I [from 20 +/- 3 to 12 +/- 3 mmHg, P < 0.001] with insignificant increase in HVPG in group II. Insignificant correlation between MAP and HVPG was observed. No deterioration of kidney or liver functions were observed. No recorded hypotensive attacks or deaths in both groups

Conclusions: [1] Combination Of endoscopic sclerotherapy and valsartan is superior to sclerotherapy alone in inducing variceal obliteration and decreasing variceal rebleeding in class A and B cirrhotic patients with ruptured oesophageal varices. [2] Valsartan, in an oral dose of 80 mg orally, has a significant portal pressure lowering effect and well tolerated in child A and B cirrhotic patients

Usefulness of carotid intima-media thickness and brachial artery flow mediated dilatation in diabetic patients with suspected coronary artery disease

Objective: flow associated dilatation [FXD%] and intima media thickness are established markers of early atherosclerosis. This study aimed to compare the ability of the non-invasive measurements FAD% and intima media thickness to predict coronary artery disease in asymptomatic diabetic males

Methods: B-mode ultrasonography was used to assess both intima media thickness in the common carotid artery and endothelial function in the brachial artery in 64 non-insulin dependent diabetic male patients asymptomatic for coronary artery disease. They were divided into two groups, Group A comprise patients with positive stress test, and group B patients with negative stress test. Brachial artery diameter was measured at rest, during reactive hyperemia, and after sublingual administration of nitroglycerin

Results: patients with positive exercise stress test had reduced FAD% compared with those with negative exercise stress test [4.4 +/- 0.67 v 5.8 +/- 1.1 5%. p<0.001], whereas intima media thick-ness tended to be increased in patients with positive exercise stress test but not statistically significant [1.1 +/- 0.16 v 0.96 +/- 0.0lmm, p > 0.05]. There was a negative correlation between FAD% and intima media thickness [r =-0.498, p <0.001]. Receiver operating character-istic analysis showed that FAD% > 4.6% predicted coronary artery disease with a sensitivity of 0.70 and a specificity of 0.87

Conclusions: brachial artery FMD may become a useful tool for screening diabetic male patients with suspected CALI while determination of increased intima media thickness is not useful in discrimina between presence or absence of coronary artery disease

Gallstones in bilharzial hepatic fibrosis: relationship to gall bladder contractility, plasma cholecystokinin and portal hypertension

Background: defective gall bladder [GB] contractility has been proposed as a possible pathogen etic factor to explain the increased prevalence of gallstones in chronic liver diseases. However, GB contractility in bilharzial hepatic fibrosis has not been adequately studied

Aim of the work: to study the changes in GB contractility and plasma cholecystokinin [CCK] levels in patients with bilharzial hepatic fibrosis with and without gallstones. Also, the impact of portal hypertension on GB contractility was evaluated

Subjects and Methods: thirty-six patients suffering from bilharzial hepatic fibrosis [17 male, 19 female; aged 43.97+/-9.48 years] and 15 healthy control subjects matched in age and sex with the patients group were included in the study. All studied subjects were subjected to thorough medical examination and liver function tests. Fasting and postprandial CCK were assayed using radioimmunoassay. Fasting and residual GB volumes and GB ejection fraction were determined by ultrasonography as measures of GB contractility. Congestion index was estimated as a measure of portal hypertension

Results: patients with bilharzial hepatic fibrosis had significantly higher values of fasting and residual GB volumes and significantly lower values of GB ejection fraction than did control subjects [40.97+/-14.77ml Vs 24.4+/-5.87ml, P<0.001; 18.72+/-10.5ml Vs 7+/-2.33ml, P<0.001; 57.08%+/-13.78 Vs 71.26%+/-6.66, P<0.001, respectively]. There were significant increase in fasting and postprandial total CCK values in patients compared to control subjects. Bilharzial hepatic patients with gallstones exhibited significantly larger fasting and residual GB volumes and significantly reduced GB ejection fraction, in comparison to those without gall stones. Bilharzial hepatic patients with gallstones had significantly higher values of portal vein diameter and congestion index than did those without gallstones. For fasting and postprandial CCK, patients harboring gallstones had significantly higher levels than those without gallstones. GB ejection fraction correlated positively with serum albumin [r = 0.56, Pc0.001]. Postprandial CCK correlated positively with residual GB volume [r = 0.77, P<0.001] and negatively with GB ejection fraction [r = -0.58, P0.001]. Fasting and residual GB volumes correlated positively with both portal vein diameter and congestion index. GB ejection fraction correlated negatively with portal vein diameter [r= -0.47, P = 0.003] and congestion index [r = -0.56, P<0.001]

Conclusion: our study provides an objective evidence of impaired GB contractility in patients with bilharzial hepatic fibrosis in spite of higher CCK values especially in those harboring gallstones. Also, bilharzial hepatic patients with gallstones had significantly higher measures of portal hypertension than those without gall stones. The GB hypo contractility correlated to measures of portal hypertension. Therefore, our results suggest that defective GB contractility might contribute to the increased frequency of gallstones in patients with bilharzial hepatic fibrosis. Portal hypertension per se may have a role in the increased genesis of gallstones. Further researches are recommended to study whether portal decompressive drugs could decrease the incidence of gallstones in patients with bilharzial hepatic fibrosis

Carotid body tumors: challenging complexity of diagnosis and surgical management

The tumor of the carotid body tumor [CBT], is a rare tumor, only about 1000 cases had been reported in the literature. It's of obscure origin and misdiagnosed if it is suspected. CBT is usually benign and commonly presented as a non-painful cervical mass. The aim of this study was to analyze diagnostic and therapeutic aspects and complications of surgery of CBT in Mansoura University Hospitals. We present eight patients had 10 carotid body tumor. Male to female ratio was [1: 2], age ranged between 13-72 years in the period between May 2000 to December 2003. The aim of this study was to analyze diagnostic and therapeutic aspect and complications of surgery of CBT in Mansoura University Hospitals. All patients were identified and complete radiological study was done including CT, MRI, Doppler Ultrasound and Angiography. Clinically, there were no secreting tumors in these patients. Preoperative immobilization was done in seven cases 24hours before surgery. All patient were operated on for tumor resection. Result the blood loss for these patients was fewer than those without immobilization. Only one case needed resection of the carotid and interposition graft. One patient had preoperative nerve deficit. Neurological deficits were noted in three patients out of nine patients [33%] immediately after surgery and two patients out of seven had permanent deficit [29%]. One patient deceased in the postoperative period from pulmonary embolism [12.5%]. Our conclusion is: the diagnosis of CBT is depending on suspicious, radiology is essential. Embolization decreases blood loss and facilitates tumor removal. Observation is not recommended because of the progressive behavior of the tumor associated with increased risk of neurological deficit. Surgery is the treatment of choice with minimal morbidity and mortality

Congestion index of the portal vein and other predictors of variceal bleeding in portal hypertensive patients

Rupture of esophageal varices is the most common cause of massive, life threatening hemorrhage from the esophagogastric segment and portal pressure is necessary for rupture of varices but not all patients with elevated portal pressure bleed and local factors play a role. This study was designed to clarify the possible contribution of clinical risk factors and en-doscopic findings with portal hemodynamic changes in initiation of variceal bleeding. The study comprised 50 patients with liver cirrhosis and portal hypertension, 30 of them had a history of previous variceal bleeding and the other 20 patients didn't bleed before. After through history taking and clinical examination, liver function tests and complete blood picture were done, abdominal ultrasonography and Doppler study for the portal vein were performed and the congestion index of the portal vein [CI] was calculated and then upper gastrointestinal endoscopy was done. Results showed that mild to moderate splenomegaly, presence of ascites, increase in Child-Pugh score, thrombocytopenia and low prothrombin activity were associated with more variceal bleeding. Also results showed that CI of the portal vein was highly significantly increased in bleeders when compared to non-bleeders. The endoscopic prognostic index [PI] which depends on the size of esophageal varices, presence of gastric varices and congestive gastropathy was highly significantly increased in bleeders than in non-bleeders. Correlation studies showed that CI was positively correlating with Child-Pugh score and PI and it was negatively correlating with platelets count. From the above we can conclude that, for portal hypertensive patients, Echo Doppler of the portal vein which is a cheap and non-invasive technique should be done to select those with high CI to be submitted to endo-scopic screening for large and risky varices who would benefit from the available pharmacological and endoscopic prophylactic therapies

Percutaneous catheter drainage of liver abscesses

Imaging-guided percutaneous catheter drainage of hepatic abscesses [PAD] was done in 39 patients. Amebic liver abscesses were diagnosed in 18 patients, where 17 patients had pyogenic liver abscesses and 4 patients had indeterminate abscesses. Right lobe abscesses were seen in 32 patients and left lobe abscesses were seen in 7 patients. PAD was successful in 36 patients [92.3%], emergency laparotomy was indicated in one case who developed clinical signs of peritonitis and in two cases the condition deteriorated due to insufficient catheter drainage with C.T. evidence of persistent abscess cavity and both were drained by open surgery. 1- year follow up was available for all patients with no reported abscess recurrence. Complications developed in 4 cases [10.3%] in the form of bacteraemia [3 cases] and pneumothorax [one case]. The catheter drainage time ranged from 3 to 35 days [mean = 16 days]. PAD of hepatic abscesses is an effective, relatively safe and permanent therapeutic method. It can be used as a safe alternative to surgery, except of there is an underlying liver disease

Evaluation of portal hemodynamics in patients with refractory ascites before and after periteneo-venous shunt

Twenty patients with tense refractory ascites due to bilharzial and/or posthepatic cirrhosis [age ranged 30-60 years] were carefully selected for Denver peritoneojugular shunt [PJS] and followed up clinically and the portal vein was examined before and after shunt for evaluation of portal hemodynamics. The shunts were effective in relieving medically resistant ascites. The portal pressure increased, especially in the early postoperative period and then gradually decreased to the preoperative value. Denver peritoneovenous shunt has a higher patency rate and it is associated with fewer complications. Partial paracentesis, potent diuretics and beta blocker was recommended immediately before operation to minimize the incidence of variceal hemorrhage after shunt due to increase in portal pressure

Computed tomography versus magnetic reasonance imaging in diagnosis of congenital cystic intracranial lesions

Twenty one cases of congenital cystic intracranial lesions [having a range of age 24 days to 15 years] were subjected to CT and MRI examinations. The imaging findings were compared with the final diagnosis obtained by clinical data, operation and follow up. The lesions appeared mostly as hypodense nonenhancing masses of CSF density by CT, exerting mass effect according to the size and no surrounding edema. By MRI, they appeared hypointense in T1WI and hyperintense in T2WI. The pathological varieties encountered were; 2 cases of holoprosencephaly, 2 hydranencephaly, one porencephaly, 8 Dandy walker [DW] complex, 7 arachnoid cysts, and one epidermoid tumour. Both CT and MRI can give similar informations concerning the size, shape, rim thickness and other morphologic characteristics of cystic intracranial lesions. Additional data given by MRI are; superior visualization of cerebellar vermis in cases of Dandy Walker complex hence it could be classified into [type A] with absent vermis and [type B] with present vermis in the axial MRI cuts for the fourth ventricular level. MRI is better for detection of infection in an arachnoid cyst by the presence of high signal intensity inside the cyst, It is also able to predict the nature of the contents of the epidermoid cyst whether protein or triglycerides according to its signal intensity in both T[1] and T[2] WI. MRI can detect abnormal signal intensity in the cyst wall of a porencephalic cyst that helps differentiation from arachnoid cysts. Also MRI has a better performance specially in posterior fossa lesions as it is not affected by beam hardening artifact as CT. Other advantages of MRI include lack of ionizing radiation and direct visualization of blood flow, Muliplanar capability and high soft tissue resolution. CT is superior to MRI in the detection of calcification in certain lesions as epidermoid cyst

Computed tomography and MRI evaluation of mucoceles of the paranasal sinuses with reference to intracranial and extracranial extensions

15 patients with mucoceles of the paranasal sinuses were studied, the commonest sinus to be involved was the ethmoid followed by the frontal maxillary and spheno-ethmoidal, while sphenoid sinus alone was not involved. All the cases were subjected to computed tomography and only 2 cases were examined by magnetic resonance imaging. CT was usually sufficient for making diagnosis and defining the extent of the lesion, accurately demonstrating the orbital and intracranial extensions by both axial and coronal sections. All cases were explored surgically verifying the extension and the chronicity. MRI was very valuable in detecting the nature of the mucocele by high T2-Wls, while Tl-Wls differed according to the chronicity of the mucocele also MRI by its multiplanner capability demonstrated the extent of the lesion. One drawback of the MRI was its poor demonstration of the bones and calcifications of the sinuses, while high resolution CT demonstrated bone details and intracranial extension better. T2-weighted image and it displays the sinus in 3 plane imaging with direct sagittal sections

Correlation of CT and operative staging in cancer head of the pancreas

In a current series of 150 patients with obstructive jaundice studied by abdominal CT, there were only 30 cases with operatively proved pancreatic carcinoma. A correct CT diagnosis was made in 24 cases [80%] while 6 patients [20%] were incorrectly diagnosed. The primary CT finding of pancreatic carcinoma was a tumour mass with associated bile and or pancreatic duct dilatation. The mass was located in the head in 28 cases [93%] and involved most of the gland in 2 cases [7%]. On CT, the mass was demonstrated as a central hypodense zone in 18 cases representing the hypovascular scirrhous tumour surrounded by normal parenchyma or inflammatory tissue caused by obstructive pancreatitis. In 6 cases, the mass was heterogenous in density. The common bile duct was dilated in all of our cases. A dilated pancreatic duct was seen in 12 cases, Tumour obstruction of the main pancreatic duct causing rupture of lateral side branch ducts resulted in the formation of post obstructive pseudo-cysts in 2 cases. Knowledge of this finding is important to avoid the mis-diagnosis of a tumour as pancreatitis with pseudocysts. The secondary findings of local tumour extension or metastatic diasease help to differentiate malignant masses from benign ones and aid in tumour staging and resectability. One or more of the ancillary findings were seen in 22 out of 24 correctly diagnosed cases. CT diagnosed resectable tumours in 2 cases. During operation however one case only was resectable