Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) with radial scanning is an efficient diagnostic tool where there is suspicion of common bile duct (CBD) stones. Little is known about the use of linear EUS in this condition. The aim of this study was to evaluate the diagnostic efficiency of linear EUS in a large group of patients suspected to have bile duct stones, using endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and exploration of the CBD using a Dormia basket, or surgical choledochotomy with choledochoscopy, as diagnostic "gold standards." PATIENTS AND METHODS: 134 patients with clinical suspicion of CBD stones were included in the study and prospectively evaluated, using EUS, and ERCP with endoscopic sphincterotomy (127 patients), or choledochotomy with choledochoscopy where ERCP was unsuccessful (seven patients). EUS was done before ERCP using an echo endoscope (Pentax FG 32 UA; 5 - 7.5 MHz) and Hitachi EUB 405 ultrasound machine. ERCP was done using the TFJ 100 or TJ 20 Olympus duodenoscope. ERCP was carried out within a mean of 2 days after EUS. The longest time between EUS and ERCP was 3 days. The examiners were blinded to the results of the other method used. RESULTS: CBD stones were found in 91 (68 %) patients at ERCP with ES or at surgery. The correct diagnosis was established by EUS in 85 patients. The remaining 43 patients without CBD stones were correctly diagnosed in 41 cases by means of EUS, giving an accuracy of 94 %, sensitivity of 93 %, specificity of 93 %, a positive predictive value of 98 %, a negative predictive value of 87 %, and a Youden's index of 89 %. CONCLUSIONS: Linear EUS is a fairly reliable method for the evaluation of patients with high suspicion for CBD stones. The usefulness of linear EUS in the evaluation of patients with low or moderate suspicion for CBD stones warrants further study.

A prospective, randomized, placebo-controlled trial of prednisone and allopurinol in the prevention of ERCP-induced pancreatitis.

BACKGROUND AND STUDY AIMS: Acute pancreatitis is the most frequent and difficult-to-avoid complication of endoscopic retrograde cholangiopancreatography (ERCP). Corticosteroids, potent anti-inflammatory drugs, and allopurinol--a xanthine oxidase inhibitor that blocks the generation of oxygen-derived free radicals--may be potentially effective in preventing post-ERCP pancreatitis. The aim of this prospective study was to determine the effect of prophylactic oral corticosteroids and allopurinol on the incidence and severity of procedure-induced pancreatitis. PATIENTS AND METHODS: 300 patients were randomly assigned to receive oral prednisone (40 mg), allopurinol (200 mg), or placebo 15 h and 3 h prior to ERCP. The diagnosis and grading of ERCP complications were based on commonly accepted criteria. Patients receiving prednisone or allopurinol were compared with the placebo group in a search for differences in pancreatitis rates associated with endoscopic techniques. RESULTS: The overall incidence of pancreatitis was 10.7 %, with 12 % in the prednisone group, 12.1 % in the allopurinol group, and 7.9 % in the placebo group. There were no statistical differences in the incidence or distribution of severity grades between the groups, although severe pancreatitis occurred only in the prednisone and allopurinol groups. Multiple cannulations and prolonged manipulations of the papilla of Vater were identified as risk factors for ERCP-induced pancreatitis. CONCLUSIONS: Neither prednisone nor allopurinol showed a beneficial influence on the incidence and severity of post-ERCP pancreatitis.

The frequency of bile duct crystals in patients with presumed biliary pancreatitis.

BACKGROUND: Previous studies of biliary microlithiasis in acute pancreatitis of uncertain etiology were conducted a few weeks to months after the acute episode. Bile obtained during urgent ERCP (less than 24 hours after admission) was studied for the presence of microlithiasis during the acute phase of acute pancreatitis of suspected biliary origin. METHODS: Fifteen consecutive patients with acute pancreatitis of suspected biliary origin were recruited from a population of 309 patients with acute pancreatitis (5%) treated during the last 4 years. Patients with gallstones on US and/or ERCP and those in whom the etiology of acute pancreatitis was certain were excluded. RESULTS: Microlithiasis (mostly calcium bilirubinate granules) was found in 12 (80%) cases. Despite endoscopic sphincterotomy 3 patients died within 2 weeks because of multisystemic organ failure. Among the 12 remaining patients, 2 (16%) developed gallbladder stones and 1 underwent cholecystectomy for cholecystitis (8%) during follow-up. The average length of follow-up was 30 months. No episodes of acute pancreatitis were noted during follow-up. CONCLUSIONS: In the acute phase of acute pancreatitis of suspected biliary origin, biliary microlithiasis was found in most cases. Endoscopic sphincterotomy appears to protect patients from further episodes of acute pancreatitis.

[Surgical intraduodenal drainage of bile duct: an introductory report]. / Operacyjny dodwunastniczy drenaz drogi zólciowej--doniesienie wstepne.

UNLABELLED: Reconstructing operations, performed on extrahepatic bile ducts, usually need protection of anastomosis by means of drainage. Classic Kehr's drainage is loaded with the risk of complications. Since 1993 the authors have been applying the alter way of drainage: an intraduodenal drainage by endoprothesis Y (DEY). Endoscopical removal of the drain was performed in 3-4 months after the operation. This way of drainage was used between III 1993--V 1997 in 23 patients. We did not observed any complications or pancreas reactions. Clinical control of patients was made after operation with ECW. In 4 cases the results of treatment were unsuccessful. In other 16 patients results of performed operations were favourable. CONCLUSION: Proposed way of protection of bile duct's reconstruction's site using DEY decreases the number of complications connected with classic Kehr's drainage.

[Endoscopic ultrasonography in the preoperative localization of a pancreatic tumor producing insulin (insulinoma)]. / Ultrasonografia endoskopowa w przedoperacyjnej lokalizacji guza trzustki produkujacego insuline (insulinoma).

Pancreatic endocrine tumors include insulinomas, gastrinomas and some other less frequent neoplasms produce different GI hormones. Preoperative localization of the tumor in patients with evident clinical and biochemical features is usually difficult to obtain in conventional imaging methods. This is due to typically small size of these tumors. Non-invasive methods (conventional ultrasound, computerized tomography, nuclear magnetic resonance, positron emission tomography) and invasive methods (visceral angiography, portal veins catheterization) are often of no use in such condition, as their sensitivity is low. Preoperative localization is of importance for the surgeon, as he can plan his operation for reducing the length of the procedure with obvious consequences. This paper describes for the first time on Polish literature the usefulness of endoscopic ultrasonography in preoperative assessment of insulinoma in one patient. This finding was confirmed during surgery. The operation led to enucleation of two small insulinomas in the head of the pancreas and resulting in complete healing of the patient as found in one year follow up.

[Effect of elimination of supratentorial aneurysms by micro- surgical method on early structural and functional changes near the operation site]. / Wplyw wylaczenia tetniaków nadnamiotowych sposobem mikrochirurgicznym na wczesne, strukturalne i czynnosciowe zmiany w otoczeniu miejsca operacji.

On the basis of neurological, psychological and computed tomographic studies of the head early consequences of microsurgical elimination of supratentorial brain aneurysms were analysed in a group of 37 patients. It was shown that this method of aneurysm treatment may lead to brain oedema near the operation site. Oedema development was observed most frequently in cases of prolonged pressure exerted by spatulae on the brain tissue during the operation, aneurysm location in the anterior cerebral artery system and in cases operated on from 4 to 10 days after subarachnoid haemorrhage.

[Diagnosis of progressive open internal hydrocephalus in patients after cranio-cerebral injuries and subarachnoid hemorrhage]. / Rozpoznawanie postepujacego otwartego wodoglowia wewnetrznego u chorych po urazach czaszkowo-mózgowych i krwotokach podpajeczynówkowych.

Late internal hydrocephalus has been diagnosed in 68 (44%) out of 154 patients treated for the ruptured cerebral aneurysms, and in 37 (31%) out of 120 patients, who underwent cranio-cerebral trauma. To establish the indications for shunts, CT scans of the skull, tomoventriculography, and infusion tests have been carried out in 38 patients. It has been found, that increased transparency of the areas below cerebral ependyma, the lack of cerebral cortex sulci, and imaging of the temporal horns together with internal hydrocephalus in CT scans indicate an active process and are indications to shunting. If there are no signs of active process in CT scans despite of the presence of hydrocephalus, tomoventriculography should be performed to establish more fully the indications to shunting.

[Highly differentiated cancer or adenoma of the liver: diagnostic approach in highly differentiated epithelial tumors of the liver]. / Wysokozróznicowany rak czy gruczolak watroby: taktyka postepowania diagnostycznego w wysokozróznicowanych guzach nablonkowych watroby.

High-differentiated hepatocellular carcinoma (h-d HCC) is a not frequent hepatic tumour but its outcome may be beneficial when treated properly. Two cases of h-d HCC recognized on the basis of postoperative histopathology are reported. We have discussed the role of fine needle biopsy in distinguishing h-d HCC from liver adenoma, and we have attempted to outline the diagnostic approach in clinically silent hepatic tumours which are not associated with cirrhosis or elevated alfa-fetoprotein plasma level.

[Effects of classical and microsurgical methods of exclusion of cerebral aneurysms on the structural and functional changes near the operation site]. / Wplyw klasycznego i mikrochirurgicznego sposobu wylaczania tetniaków mózgu na strukturalne i czynnosciowe zmiany w otoczeniu miejsca operacji.

The effects of classical and microsurgical methods of exclusion of supratentorial intracranial aneurysms on the development of ischaemic changes at the site of approach to the aneurysm were studied. In cases of internal carotid artery aneurysms and middle cerebral artery aneurysms the use of microscope reduced the occurrence of ischaemic changes at the site of approach. In cases of aneurysms of the anterior cerebral artery system the frequency of these changes was similar with both methods. The size and location of these changes and the degree of psychical changes caused by them were similar with both methods.

[Manometric evaluation of the effects of intravenous administration of glucagon, buscopan and papaverine on the contractile activity of the sphincter of Oddi]. / Manometryczna ocena wplywu dozylnego podania glukagonu, buskopanu i papaweryny na czynnosc skurczowa zwieracza Oddiego.

Endoscopic manometric technique was used to investigate the effects of spasmolytic drugs on the sphincter of Oddi (s.O.) motility. 41 patients were randomly divided into 4 groups. In every patient the characteristics of the s.O. was monitored before and during 5 min. period after i.v. administration of: 20 mg buscopan, 1 mg glucagon, 40 mg papaverine or 2 ml of 0.9% NaCl solution. After buscopan administration the amplitude and frequency of phasic contractions of the s.O. were decreased as well as a baseline pressure in the s.O. Glucagon reduced frequency and amplitude of phasic contractions of the s.O. without influencing the baseline pressure. Papaverine reduced only frequency of phasic contractions. Physiological saline caused no change in pressure characteristics of the s.O.

[Emergency endoscopic sphincterotomy in acute obstructive cholangitis]. / Dorazna sfinkterotomia endoskopowa w ostrym zaporowym zapaleniu dróg zólciowych.

In 45 patients with acute obstructive cholangitis (AOC) endoscopic sphincterotomy (ES) was performed within 24 hours after admission. Criteria for the diagnosis of AOC were as follows: clinical symptoms consisting of fever and chills, right upper abdominal pain, and jaundice (Charcot's triad) with coexisting laboratory data as elevated WBC, ERS, bilirubin level and evidence of obstructive biliary disease confirmed by endoscopic retrograde cholangiopancreatography. The causes of AOC were: in 38 patients (84.5%)--common bile duct stones, in 2 patients (4.5%)--carcinoma of the papilla of Vater, and in 5 patients (11%)--benign stenosis of the papilla of Vater. A rapid clinical improvement was observed in 40 patients after ES. Within 24 hours after ES patients had relief of pain, fever subsided and white blood cell count returned from 11.7 +/- 6.9 G/l to 7.0 +/- 3.0 G/l. Bilirubin level decreased from 101 +/- 86 mumol/l to 77 +/- 68 mumol/l. Endoscopic drainage failed only in 4 patients (9%) who required surgery. One patient (2%)--died. In the treatment of acute obstructive cholangitis urgent endoscopic sphincterotomy should be a method of choice. Surgery should be reserved only for patients in whom ES failed.

Inhibitory effect of cigarette smoking on gastric emptying of a solid meal in patients with type I gastric ulcer.

The effect of cigarette smoking on gastric emptying (GE) of a radio-labelled solid meal was examined in 14 patients with type I gastric ulcer diagnosed at endoscopy. The patients underwent GE measurement thrice: under basal conditions and for two smoking sessions--without and after cimetidine pretreatment (2 x 400 mg orally for 2 days and 400 mg orally 1.5 h before the isotopic GE examination). Cigarette smoking significantly delayed GE--the median GE index, Ix: 0.688 min-1.10-2 (range 0.033-1.886) after smoking vs. 1.246 min-1.-2 (range 0.384-2.339) under basal conditions, p less than 0.01. The inhibitory effect of smoking on solid GE was blunted when smoking coincided with cimetidine pretreatment--the median Ix amounted to 1.069 min-1.10-2 (range 0.022-1.462) and was not significantly different from that under basal conditions.

[Difficulties in the diagnosis of pancreatic cancer using endoscopic retrograde cholangiopancreatography]. / Trudnosci rozpoznawania raka trzustki w obrazie endoskopowej pankreatocholangiografii wstecznej.

Difficulties are presented which the authors met on ERCP-evaluation of the pancreatic cancer. 64 cases were analyzed of the diagnosed cancer, then confirmed on surgery, histopathologically+ and post mortem. Differentiation of the cancer from chronic pancreatitis was most difficult with the false positive results being 20.3.

Effect of cigarette smoking on gastric emptying in patients with an active duodenal ulcer.

The effect of cigarette smoking on gastric emptying (GE) of a radiolabelled solid meal was examined in 14 patients with an active duodenal ulcer. The patients underwent GE measurement thrice: under basal conditions and for two smoking sessions, without and after cimetidine pretreatment (2 X 400 mg orally for 2 days and 400 mg orally 1.5 h before the isotropic GE examination) in random order. Cigarette smoking significantly delayed GE (p less than 0.05 for both the gastric half emptying time (H) and the mean transit time (MTT90)). The inhibitory effect of smoking on GE was enhanced after cimetidine pretreatment (p less than 0.02 for H and p less than 0.004 for MTT90, respectively). Potential mechanisms and pathophysiological meaning of the findings are discussed.

Cigarette smoking delays gastric emptying of a radiolabelled solid food in healthy smokers.

The effect of cigarette smoking on gastric emptying was studied in 18 healthy volunteers by means of an isotopic method. Although the observed individual reactions were fairly variable, cigarette smoking significantly delayed gastric emptying of a solid meal. Potential mechanisms of action of cigarette smoking on gastric emptying are discussed, including the role of nicotine. The method of gastric emptying measurement was shown to be reproducible in the paired studies performed in 11 subjects.