Rare localization of a portal cavernoma in the wall of the common bile duct.

The first communication on biliary complications secondary to a portal cavernoma was published in 1965 [Br. J. Surg. 52 (1965) 636.], and since then several cases have been reported in the medical literature. These biliary complications, studied initially by anterograde or retrograde cholangiography, and later MR cholangiography [Van Hoe L, Van Beckevoort D, Van Steenbergen W. Atlas of across-sectional and projective MR cholangiography. Berlin: Springer; 1999. p. 166-7.], appear to be secondary to a double mechanism which produces a compression of the common bile duct (CBD) and ischemic changes. The biliary abnormalities most frequently found are a dilatation of the intrahepatic biliary ducts associated with extrinsic strictures and segmental dilatation of the CBD [J. Radiol. 83 (2001) 341.]. We report a rare type of portal cavernoma characterized by a thickening of the walls of the CBD and by a dilatation of the intrahepatic biliary ducts. The thickened walls of the CBD were evaluated by ultrasound and by magnetic resonance imaging.

[Cystic dystrophy in heterotopic pancreas of the second part of the duodenum. One case of conservative surgical procedure]. / Dystrophie kystique du deuxième duodénum sur pancréas aberrant. Un cas de traitement chirurgical conservateur.

Duodenal cystic dystrophy due to ectopic pancreas deposit is an uncommon pathology. Diagnosis is made by modern imaging techniques, mainly endoscopic ultrasound which localizes precisely cysts in duodenal wall. The most frequent clinical symptoms are pain, duodenal obstruction, and weight loss. We report the case of a 40 year-old man with cystic dystrophy of the 2nd part of the duodenum, without chronic pancreatitis, treated by a conservative surgical procedure including segmental duodenal resection. This original approach is an alternative to the Whipple procedure.

Correction of malnutrition following gastrectomy with cyclic enteral nutrition.

This study was designed to evaluate the efficacy and tolerance of cyclic enteral nutrition (CyEN) in gastrectomized patients and to compare the nutritional response to refeeding of 28 gastrectomized patients and 38 nongastrectomized undernourished patients. Total (enteral + oral) energy intake (292% and 284% of resting energy expenditure in gastrectomized and nongastrectomized patients, respectively) and the duration of CyEN (27 days) were similar in both groups. Tolerance was good and not different in the two groups. In the gastrectomized patients, a global nutritional deficiency score based on 10 biological and anthropometric parameters significantly improved (P < 0.0001) with six of the 10 nutritional parameters studied being improved by renutrition. Comparison of the two groups revealed similar efficacy of refeeding; the global nutritional deficiency score improved by 42.7 +/- 17.3% in group 1 and 40.0 +/- 17.4% in group 2. After one year, the probability of being alive without relapse was 77.8% in the gastrectomized and 72.2% in the nongastrectomized patients (P = 0.70). The efficacy of renutrition was similar regardless of the type of gastrectomy (eg, partial or total). CyEN is a safe, effective and durable treatment for undernutrition in gastrectomized patients.

[Mesenteric arterial thrombosis in protein S deficiency]. / Thrombose artérielle mésentérique au cours d'un déficit en protéine S.

Arterial thrombosis is very rarely described in patients with coagulation factors deficiency. We report the first case of superior mesenteric artery thrombosis of a normal mesenteric artery associated with protein S deficiency, causing massive mesenteric infarction with short bowel syndrome. Eight-month parenteral nutrition and definitive antivitamin K anticoagulation were required in this 72 year-old patient. The initial oral anticoagulant malabsorption disappeared a few months later as clinical and biological course improved. Rapid intestinal adaptation was probably consecutive to early enteral refeeding. The possibility of reintroducing antivitamin K despite initial inefficacy should be stressed, as well as the necessity of an exhaustive coagulation work-up in patients with mesenteric infarction.

Multidisciplinary day hospital treatment of rheumatoid arthritis patients. Evaluation after two years.

The availability of multidisciplinary care for rheumatoid arthritis is still limited. The Raoul Dufy Program offered by the Saint-Antoine Teaching Hospital in Paris provides one-on-one personalized care in a day hospital setting as an adjunct to conventional medical follow-up. Listening and providing information and education are major objectives of the nurse, rheumatologist and physical therapist participating in the program. The team also includes a social worker, a surgeon, a dietician, a podiatrist and a psychologist, who intervene as needed. Seventy patients attended the program between December 1993 and September 1995 and were asked to complete a baseline and a three-month questionnaire designed to evaluate the effects of the program in terms of new therapeutic interventions, patient knowledge and quality of life. The patient knowledge score increased significantly (P < 0.0001). Many therapeutic interventions were initiated after program attendance, especially in the fields of podiatry, psychology and physical therapy. However, the quality of life score failed to improve. These results and the substantial patient demand for appointments are encouraging. Further work is needed on the methodology of multidisciplinary care evaluation. Coping strategy evaluation tools may allow to identify some of the specific benefits provided by the multidisciplinary approach.

Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients.

Previous reports suggest that correcting the malnourished state may be more difficult in elderly people than in younger people. The aim of this study was to evaluate the effect of 21 days of cyclic enteral nutrition (CyEN) on nutritional and body composition parameters in elderly, compared with younger patients. Twenty-four patients younger than 65 years (mean age 50 years) and 26 patients 65 years of age and older (mean age 75 years) referred for refeeding, having lost at least 20% of their body weight or at least 10% in 3 months, were studied. All patients were ambulatory. Cyclic enteral nutrition was administered nocturnally via a nasogastric tube; in the daytime patients were allowed to eat normally and to walk. Resting energy expenditure was measured at day 0 by indirect calorimetry. Ten anthropometric and biological nutritional parameters and a global nutritional deficiency (GND) were measured at day 0 and 21. Body composition was measured at day 0 and 21 by bioelectric impedance analysis. Total energy intakes were 286% and 280% of resting energy expenditure in groups 1 and 2, respectively. Body weight, serum prealbumin, serum transferrin, 24 h urinary creatinine, and the GND (39.9% vs 23.3%; P < 0.01) improved significantly more in younger than in elderly patients. Fat free mass (3.9 vs 2.4 kg; P < 0.05) and body cell mass (2.7 vs 1.6 kg; P < 0.01) but not fat mass improved significantly more in younger than in elderly patients. In conclusion, 21 days refeeding by cyclic enteral nutrition with similar energy amounts is less effective to correct malnutrition in elderly than in younger patients.

Correction of protein-energy malnutrition in older adults: effects of a short-term aerobic training program.

Twenty malnourished subjects (average age 67 years old) treated by cyclic enteral nutrition were assigned to an active or control group according to whether they took part or not in a 3-week aerobic training program. Subjects underwent the following tests on d(0)-d(1) and d(20)-d(21): calculation of a global nutritional deficiency index (GND), bioelectrical impedance analysis, evaluation of daily energy expenditures using a 24 h heart rate (HR) recorder and a pedometer, maximal voluntary isometric strength assessment (MVIS), and symptoms limited maximal oxygen uptake ((.)VO(2 max. SL) estimation. Although energy intakes were similar in both groups, active subjects showed greater improvements (P < 0.05) than control subjects regarding GND (-9.8 vs -4.8%), serum albumin and prealbumin. Active subjects also showed a greater increase (P < 0.05) in pedometer readings compared to control subjects. Reduction of resting HR was observed in active (-5 beat/mn, P < 0.05) whereas no significant changes in average HR were noted in either group, reflecting increased metabolic activity. Compared to control, active subjects showed significant (P < 0.05) improvements in MVIS (0.8 vs 0.1 N/kg) and (.)VO(2 max. SL) (5.5 vs 1.4 mL/min/kg). Short-term aerobic training has positive effects on nutritional recovery and functional capacities in elderly malnourished subjects and should be recommended whenever possible.

Resting energy expenditure in patients with alcoholic chronic pancreatitis.

The aim of this study was to assess resting energy expenditure in patients with chronic pancreatitis; 33 patients with alcohol-related chronic pancreatitis (group 1: 13 normal weight, group 2: 20 underweight) and 11 undernourished patients without identifiable disease (group 3) were studied. Body composition was determined by bioelectric impedance analysis and fat-free mass was similar among the three groups (76.4 +/- 1.5%, 78.6 +/- 1.3% and 76.8 +/- 2.1% for groups 1, 2, and 3, respectively). The measured resting energy expenditure (REE) was higher than the predicted EE (Harris and Benedict formula and Cunningham's equation) for the underweight patients with chronic pancreatitis (group 2) (P < 0.05), but not for the two other groups. According to Cunningham's equation, 65% of the group 2 patients were hypermetabolic (REE > 110% of predicted EE) versus 23.1% and 20% in groups 1 and 3. When adjusted for fat free mass, REE was significantly (P < 0.01) higher in group 2 (35.0 +/- 0.9 kcal/kg/24 hr) than in the other two groups (30.1 +/- 0.7 kcal/kg/24 hr and 30.8 +/-1.4 kcal/kg/24 hr in groups 1 and 3, respectively). During chronic pancreatitis, weight loss is accompanied by hypermetabolism, which should be taken into consideration during nutritional support.

[Chronic hepatic encephalopathy treated by long-term intravenous administration of flumazenil in ambulatory care]. / Encéphalopathie hépatique chronique traitée de façon prolongée en ambulatoire par flumazénil intraveineux.

Treatment of chronic hepatic encephalopathy is difficult. Oral flumazenil has been proposed for long-term treatment but is not presently available on the market. We report the successful treatment of one case of chronic hepatic encephalopathy in cirrhosis without precipitating factors by low dose intravenous injections of flumazenil (Anexate, 1 mg/4 hours). Flumazenil is expensive and not always effective. We suggest reserving this treatment to highly selected patients (without precipitating factor, or after failure of first choice treatment).

[The value of mycobacteria serology in the diagnosis of tubercular hepatitis]. / Apport de la sérologie mycobactérie au diagnostic des hépatites tuberculeuses.

The causes of granulomatous hepatitis are often difficult to determine and standard diagnosis methods for tuberculous hepatitis lack sensitivity, which led us to evaluate the contribution of mycobacteria serology. The case is reported of a woman in whom a diagnosis of extrapulmonary sarcoidosis had been made on two occasions (1985, 1987) in the presence of granulomatous hepatitis. Liver histology remained identical in 1991 but the existence of positive mycobacteria serology led to the start of antituberculous treatment. The satisfactory response in terms of clinical, laboratory and histological findings confirmed this diagnostic hypothesis. When search for the etiology of granulomatous hepatitis proves negative, positive mycobacteria serology is sufficient to justify specific antituberculous treatment.

[Wirsungorrhagia complicating chronic pancreatitis associated with a neuroendocrine tumor of the pancreas]. / Wirsungorragie compliquant une pancréatite chronique associée à une tumeur neuro-endocrine du pancréas.

The authors describe the case of a female patient who presented with recurrent rectorrhagia of unexplained origin. The diagnosis was wirsungorrhagia complicating advanced calcifying chronic pancreatitis. Analysis of the surgical specimen led to fortuitis discovery of a pancreatic neuroendocrine tumour.

[Gastric leiomyosarcoma. Ultrasonographic endoscopy and MRI]. / Léiomyosarcome gastrique. Echoendoscopie et IRM.

Leiomyosarcoma of the stomach is an unfrequent tumor, for which the prognosis is better than for cancer of the stomach. Its development is often subserosal, thus explaining its clinical latency and its large volume at the time of diagnosis. While many publications report about the merits of conventional imaging for this type of pathology, few authors have considered ultrasonographic endoscopy, and even fewer magnetic resonance imaging. The authors present one case for which these two recent techniques were implemented, as well as a review of the literature.

[Results of leukocyte migration inhibition test against elastin in joint diseases (author's transl)]. / Résultats du test d'inhibition de migration des lymphocytes vis-à-vis de l'élastine dans les affections articulaires.

UNLABELLED: The purpose of this work was to report the results of the test TML inhibition of leukocytes' migration, using elastin, by Soborg and Bendixen method, modified with elastin rates of 100 micrograms and 200 micrograms/ml, in joints disease. We verified that the test is generally negative in healthy controls (1 TML positive out of 26 cases); we studied 72 patients, and 38 out of them had a positive test. TML is frequently positive in Horton disease, spondylarthritis, rheumatoid polyarthritis without corticoids, collagen disease; in this cases there is a significant difference of migration between patients and controls group. We also noted a positive TML in infections arthritis and other inflammatory but not in joint's diseases with alteration of elastic tissue (scabs and lung's injury). IN CONCLUSION: TML positive test with elastin, is not a specific test of articular injury neither a proof of its immunologic nature but it contributes in diagnostic for joints diseases.