Biliary Web: A Rare Cause of Extrahepatic Biliary Obstruction

A biliary web is a rare lesion, which may produce an extrahepatic biliary obstruction. Even though congenital in nature, they usually present later in life, due to their initial patency, which allows bile drainage from the liver. Herein, a case of an operation on an isolated mucosal web of the common hepatic duct, in a 45 years old male, is presented.

Ultravist(R) Test in Postoperative Small Bowel Obstruction

PURPOSE: To determine whether Ultravist(R) test can enable the surgeon to differentiate complete from partial small bowel obstruction in patients with adhesive small bowel obstruction and whether partial small bowel obstruction can be treated nonoperatively. METHODS: Ninety-two patients who had postoperative small bowel obstructions without any toxic signs underwent Ultravist(R) test. Ultravist(R) (40 ml) mixed with 40 ml of distilled water was administrated either orally or via nasogastric tube to each patient. Serial plain abdominal radiographs were taken 4, 6, and 8 hours later. RESULTS: A total of 58 patients (63%) whose contrast medium reached the colon within the first 8 hours were considered to have partial obstruction (test positive) and were successfully treated with intravenous hydration and nasogastric decompression. The remaining 34 patients (36.9%), in whom the contrast medium failed to reach the colon within the first 8 hours (test negative), were regarded as having complete obstruction. Twenty-three of those patients (67.6%) underwent surgery and the other 11 (32.4%) received conservative treatment. Adhesion bands with complete bowel obstruction were observed in all 23 surgical patients during laparotomy. All the patients with partial bowel obstruction were treated successfully with nonoperative methods. Positive Ultravist(R) test as an indicator for nonoperative treatment had a sensitivity of 84.5%, a specificity of 100%, an accuracy of 88% and a false negative rate of 12%. CONCLUSION: Ultravist(R) can be used to differentiate partial from complete intestinal obstruction. All patients with evidence of Ultravist(R) reaching the colon within 8 hours were treated successfully with non-operative methods.

Percutaneous Transhepatic Cholangioscopic Lithotomy in Biliary Stones

PURPOSE: Percutaneous Transhepatic Cholangioscopic Lithotomy (PTCS-L) has been reported as an effective and safe therapeutic method for complicated hepatobiliary stones, particularly in high risk patients. However, there were some limitations and technical difficulties encountered in PTCS-L. The purpose of this retrospective study was to assess the result of PTCS-L in patients with recurrent or residual hepatobiliary stones. METHODS: The medical records of 61 consecutive patients (Jan.1997~Jun.2002) treated with PTCS-L for biliary stone were reviewed. There were 29 patients with primary treatment, and 32 patients with adjuvant treatment for residual stones. PTCS-L was performed within 2 weeks following progressive exchange of PTCS catheter after PTBD. Lithotomy was combined with either electrohydraulic lithotripsy (EHL), Dormia basket, or saline irrigation under fluroscopic guide. If stone was free on one or two consecutive cholangiography after final session lithotomy, then PTCS catheter was removed, but in cases of biliary stricture, 20Fr. of PTCS catheter was placed for average 71 (ranged; 27~270) days. RESULTS: Locations of stones were intrahepatic duct (IHD) in 22 cases, common bile duct (CBD) in 22 cases, CBD & IHD in 11 cases, cystic duct stump & CBD in 3 cases, GB in 2 cases and GB & CBD in 1 case. Routes for PTCS-L were of Rt. hepatic approach (B5 or B6) in 15 cases, Lt. hepatic approach (B3) in 42 cases, both hepatic approach in 2 cases and percutaneous gallbladder drainage (PGBD) tract in 2 cases. Sessions of PTCS-L were one in 22 cases, two in 26 cases, three in 9 cases and four in 4 cases, and overall in 1.5 session. Causes of multiple session in 39 cases were biliary stricture in 13 cases (33%), impacted stones in 10 cases (26%), large stone (>2 cm) in 9 cases (23%) and anatomical variation of IHD including severe ductal angulation in 7 cases (18%), which necessitated routine combined use of EHL (total 44 cases) and sometimes fluroscopic lithotomy (3 cases). Complications encountered following PTCS-L were transient hemobilia in 11 cases, catheter dislodgement in 1 case and hepatic abscess in 1 case, but mortality was nil. During followed up of median 17 months (1~53 months), recurrence of stone occurred in 1 case and one among of 13 patients with biliary stricture underwent operation on recurred biliary stricture. CONCLUSION: PTCS-L is very useful alternative treatment to surgery for residual or recurrent stones and is highly indicated for those of high risk patients. However, Electrohydraulic lithotripsy (EHL) should be combined for those of patients with technical difficulties encountered in case of multiple large impacted stones particularly in the strictured and angulated intrahepatic ducts.

Prevalence and Associated Factors of Fall Among the Elderly in Nursing Home

BACKGROUND: Falling in elderly has caused high mortality and morbidity rates. But research papers about falling in elderly are rate in Korea. We examined preventive methods from falling in institutionalized elderly. METHODS: Subjects were 163 older adults residing in a nursing home. Investigators interviewed the subjects by questionnaries about falling, associated factors, environmental factors, and change after falling during last one year. We examined geriatric depression scale(GDS), mini mental status exam-Korea(MMSEK), Katz`s activities of daily living(ADL), Lawton`s instrumental activities of living. Also, we reviewed medical record. We use the student t-test and chi-sqrare test. RESULTS: The total number of 152 subjects were consisted of 69 men and 83 women, with the mean age of 78.8. 30.3% of subjects have experienced falling during last one year, 57.2% of them have had fear of falling, and subjects with gait abnormality were 38.8% Falling occurred most commonly in summer (32.6%) around 2pm(27.7%) on the road(26.1%), because of tripping over(37.3%) during walking (32.3%), on cement(50.5%), with slippers on (56.5%). The injured subjects by falling were 84.8% and serious injuries(fracture, sutured laceration, joint dislocation or sprain, head injury with altered consciousness, hospitalization) were 19.6%. Injuried part of the body is most common in leg (46.2%) 30.4% of subjects visited hospital or emergency room after falling. Falling resulted in decreasing activity in 52.2% of subject. The factors that were significantly associated with falling were fear of falling (p<0.05), depression (p<0.05). Past history of falling, impairment of cognitive function, dizziness were weakly associated with falling. But age, hearing visual acuity, gait abnormality, ADL, anemia, degenerative arthritis were not associated with falling. CONCLUSIONS: The prevalence of falling in elderly was high. Fear of falling and depression were significantly associated with falling. Activity is decreased after falling.