Energy expenditure in acute pancreatitis evaluated by the Harris-Benedict equation compared with indirect calorimetry.

OBJECTIVES: Enteral nutrition (EN) is recommended for severe acute pancreatitis (AP) and for biliary AP if cholecystectomy is delayed. Energy expenditure (EE) is calculated using the Harris-Benedict equation (HBE), but indirect calorimetry (IC) can also be employed. We wished to compare EE evaluated by the HBE equation, modified HBE (mHBE) and IC at study inclusion and 1 month after AP resolution. METHODS: We undertook a single-center prospective study in Paris, France. RESULTS: Among 35 patients, 19 had biliary AP and 11 alcoholic-related AP. Eleven cases had severe AP. There was no significant difference between EE calculated by the HBE and that using IC at study inclusion. However, the EE calculated by the mHBE was significantly higher than that calculated using IC. For severe AP, the HBE underestimated EE whereas the mHBE overestimated it. No difference was found based on the cause of AP. There was no difference between methods for EE at 30 days. CONCLUSIONS: The HBE underestimated EE for severe AP, whereas the mHBE overestimated it. IC seems to be the best means of EE evaluation for AP.

Elevated plasma pancreatic enzyme concentrations after Roux-en-Y gastric bypass may indicate closed loop obstruction.

Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric procedures and most patients are women of reproductive age. Consequently, general surgeons and obstetricians need to be aware that these patients are at risk of bariatric specific surgical complications during their pregnancy. We report a case involving a 32-year-old woman who had undergone Roux-en-Y gastric bypass surgery 2 years previously. She presented at 25 weeks of gestation with a closed loop obstruction due to a retrograde jejunojejunal intussusception that was initially misdiagnosed as acute pancreatitis.

[Hepatitis C virus contamination of endoscopes and biopsy forceps]. / Contamination des endoscopes et des pinces à biopsies par le virus de l'hépatite C.

BACKGROUND: Procedures such as digestive endoscopy may explain some unclear contaminations by HCV. AIMS: The aims of this study were to detect HCV genome on endoscopes and biopsy-forceps used in patients with known chronic HCV infection and to determine its presence in their gastric juice and saliva. METHODS: A gastroscopy with antral biopsies was performed in 48 patients with non-treated replicative chronic hepatitis C. Samples were obtained after pushing 10 mL of sterile water through the biopsy-suction channel and after immersing the brush used to clean this channel. The biopsy-forceps were also immersed and their tips brushed in 10 mL of sterile water. This sampling technique was repeated three times: immediately after the endoscopic procedure (T0), after washing with a detergent (T1) and after immersion for 20 minutes in a 2% glutaraldehyde solution (T2). The HCV genome was detected by polymerase chain reaction (PCR, Amplicor - Roche Diagnostics Systems). For the last 15 patients, samples of gastric juice and saliva were obtained before antral biopsies and used to detect HCV genome. RESULTS: HCV genome was detected in the biopsy-suction channel in 13 cases (27%) at T0 and in one case (2%) at T1. It was undetectable after completion of the disinfection procedure (T2). Three biopsy-forceps (6%) were PCR positive immediately after the endoscopy but none at T1 and T2. HCV genome was found in the gastric juice in three cases. In all of them, it was also found at T0 in the biopsy-suction channel but not on the biopsy-forceps. When saliva contained HCV genome (4 cases), it was present in the biopsy-suction channel in only one case. In this case, the gastric juice was also PCR positive. CONCLUSIONS: HCV genome is detected in 27% of cases in the biopsy-suction channel after an endoscopic procedure performed on patients with chronic HCV infection. The biopsy-forceps are PCR positive in 6% of cases. The infected gastric juice may play a role in the contamination of the endoscopes. The complete disinfection procedure seems effective to eliminate HCV.

Concurrent emergence of hepatitis B e antigen-negative hepatitis B virus variant and autoimmune hepatitis cured by adenine arabinoside monophosphate.

We report the case of a hepatitis B virus chronic carrier in whom features of severe autoimmune hepatitis developed concurrently with the emergence of a hepatitis Be antigen-negative variant. Corticosteroid administration failed to normalize serum transaminase activity and resulted in increased viral multiplication. Adenine arabinoside monophosphate treatment allowed simultaneous inhibition of hepatitis B virus multiplication and remission of autoimmune features. This observation indicates that hepatitis Be antigen-negative variants can induce autoimmune hepatitis and adds support to the hypothesis that autoimmune hepatitis can be triggered by hepatotropic viruses. Patients with both features should first be treated with adenine arabinoside monophosphate. This observation indicates that hepatitis Be antigen-negative variants can induce autoimmune hepatitis and adds support to the hypothesis that autoimmune hepatitis can be triggered by hepatotropic viruses. Patients with both features should first be treated with adenine arabinoside monophosphate.

[Hemorrhagic colitis and hemolytic uremic syndrome caused by Escherichia coli O157:H7]. / Colite hémorragique et syndrome hémolytique et urémique dus à Escherichia coli O157:H7.

We report the case of an Escherichia coli O157:H7 infection in a patient with hemorrhagic colitis. Initial diagnosis was ischemic colitis because of the age of the patient and clinical presentation. After one week, a hemolytic-uremic syndrome occurred and serologic antibodies to the lipopolysaccharide O157 of Escherichia coli O157:H7 were positive, leading to the diagnosis of hemorrhagic colitis caused by this bacteria. Escherichia coli O157:H7 colonic infection is not well known, specially in France where only two cases has been reported in adults. This bacteria and the toxin produced (Shiga-like toxin) should be searched in cultures of stools and colonic biopsies in case of bloody diarrhea, in particular when a hemolytic-uremic syndrome is associated. As clinical, pathological and endoscopic findings in Escherichia coli O157:H7-associated colitis may be similar to the ischemic colitis pattern, differential diagnosis may be difficult.

Primary ileal villous atrophy is often associated with microscopic colitis.

Three cases of apparent primary villous atrophy of the terminal ileum in women with chronic diarrhoea are reported. Eight cases have previously been reported in the literature. Clinical characteristics are the presence of severe chronic secretory diarrhoea with episodes of hypokalaemia combined with signs of ileal malabsorption and/or efficacy of cholestyramine. Diagnosis is based on ileoscopy and histology. An association with microscopic colitis was present in the three patients and in four cases in the literature. The pathogenesis of primary ileal villous atrophy remains unknown and may involve dysimmunity. Its association with microscopic colitis may indicate a common pathogenesis or support the hypothesis that the faecal stream or bile salts play a role in the pathogenesis of microscopic colitis.

Endoscopic ultrasonography immediately prior to laparoscopic cholecystectomy: a prospective evaluation.

BACKGROUND AND STUDY AIMS: In patients who are highly likely to have common bile duct (CBD) stones, it seems necessary to image the biliary tract before laparoscopic cholecystectomy, and endoscopic ultrasonography (EUS) is one way of doing this. The aim of this study was to compare immediate preoperative EUS to intraoperative cholangiography for imaging the CBD and for the diagnosis of CBD stones, in a population with a high risk of choledocholithiasis (as assessed by clinical, biochemical, and ultrasound criteria). PATIENTS AND METHODS: From January 1993 to August 1995, EUS was carried out in the operating room in 50 patients (11 men, 39 women; mean age 57 years) before laparoscopic cholecystectomy for symptomatic choledocholithiasis. A diagnosis of CBD stones by EUS or intraoperative cholangiography was always confirmed by instrumental exploration. An absence of stones in the CBD was established by a negative EUS and intraoperative cholangiography, as well as normal findings at clinical monitoring three months after laparoscopic cholecystectomy. RESULTS: EUS visualized the CBD in 100% of cases. Intraoperative cholangiography was successful in 94% of cases (n = 47 of 50), and after conversion to open laparotomy in eight patients. CBD stones were found in 12 patients (24%). The sensitivity, specificity, and positive and negative predictive values for EUS were 100%, 97%, 92%, and 100%, respectively. CONCLUSIONS: Immediate preoperative EUS may make it possible to select the best form of treatment in patients with CBD stones, avoiding inappropriate laparoscopic instrumental CBD exploration.

[Gastric protein loss and alcoholic cirrhosis. Study by measurement of gastric clearance of alpha 1-antitrypsin]. / Pertes protéiques gastriques et cirrhose alcoolique. Etude par la mesure de la clairance gastrique de l' alpha 1-antitrypsine.

OBJECTIVE: The aim of the study was to assess gastric protein loss in alcoholic cirrhotic patients, and to determine its role in the low serum albumin levels frequently observed in these patients. METHODS: Twenty-six alcoholic cirrhotic patients with ascites and serum albumin levels < 30 g/L were studied and compared to 6 healthy volunteers. Gastric protein loss was determined by measuring gastric clearance of alpha 1-antitrypsin. RESULTS: Gastric clearance of alpha 1-antitrypsin was 0.96 +/- 1.42 mL/h (median : 0.52; range: 0.11-6.54) in cirrhotic patients and 0.48 +/- 0.20 mL/h (median: 0.51) in healthy volunteers. Values in cirrhotic patients were not significantly different from healthy volunteers. However, 3 cirrhotic patients had high values of gastric clearance of alpha 1-antitrypsin (2.84, 3.99 and 6.54 mL/h). Their serum albumin and protein levels were significantly lower than those in the 23 other patients (P < 0.05 and < 0.03, respectively). Severe portal hypertensive gastropathy was present in two out of these 3 patients and in two out of the 23 other patients. CONCLUSION: Gastric protein loss is not significantly increased in liver cirrhosis. However, in a few patients, this loss is high and may play a role in low serum albumin levels.

[A rare cause of obstructive jaundice: peripancreatic pseudoaneurysm]. / Une cause rare d'ictère obstructif: le pseudoanévrysme péripancréatique.

We report the case of a 54-year-old-man with alcoholic calcified chronic pancreatitis complicated by jaundice and abdominal pain. Investigations (Doppler ultrasonography examination and computed tomography scan) showed peripancreatic pseudoaneurysm of the posterior and inferior pancreatico-duodenal artery and a dilatation of the common bile duct. Selective embolization of the pseudoaneurysm resulted in rapid regression of both jaundice and abdominal pain. Common bile diet compression is a rare complication of peripancreatic pseudoaneurysm. Selective embolization seems to be the first line treatment in this indication.

[Isolated and spontaneously regressive colonic neurofibromatosis]. / Neurofibromatose colique isolée et spontanément régressive.

This case report concerns a man presenting protein losing enteropathy. Multiple polypoid colonic lesions were discovered corresponding to intra and submucosal neurofibromas. No extradigestive sign was noticed, and the diagnosis of isolated colonic neurofibromatosis was upheld. Eight years later, it was observed that both protein losing enteropathy and the colonic neurofibromas had apparently spontaneously disappeared. Isolated digestive neurofibromatosis and spontaneous tumoural regressions are discussed.

[A new hereditary cause of portal vein thrombosis: the abnormal resistance to activated protein C by the Arg 506-->Gln mutation of the gene of factor V]. / Une nouvelle cause héréditaire de thrombose portale: la résistance anormale à la protéine C activée par mutation Arg506-->Gln du gène du facteur V.

We report 2 cases of portal vein thrombosis associated with a single point mutation in the factor V gene that replaces arginine in residue 506 with glutamine. This mutation induces abnormal resistance to anticoagulant activity of activated protein C and increases the risk of deep vein thrombosis. Both patients had a personal and familial history of deep vein thrombosis. Intraabdominal neoplasia or infection, myeloproliferative disorder, antiphospholipid syndrome, paroxysmal nocturnal hemoglobinuria and coagulation inhibitor deficiency (antithrombin, proteins C and S) were excluded by exhaustive investigation. However, an abnormal resistance to activated protein C was found, and DNA analysis showed the factor V Arg506 to Gln mutation in both cases. Anticoagulant treatment was begun. A study of family history made in one case, showed the same genetic disease in one of the relatives. Resistance to activated protein C with factor V gene mutation should be investigated in patients with portal vein thrombosis. A study of family history, and anticoagulant treatment are justified for symptomatic patients.

[Pseudotumoral aspects of the ileocecal valve in post-antibiotic colitis]. / Aspect pseudo-tumoral de la valvule iléo-caecale au cours d'une colite post-antibiotique.

The authors report a case of acute hemorrhagic colitis following amoxicillin therapy, characterized by a tumor-like lesion of the ileo-cecal valve. Clinical symptomatology and endoscopic lesions disappeared within a few days after withdrawal of the antibiotic.