Octreotide for esophageal variceal bleeding treated with endoscopic sclerotherapy: a randomized, placebo-controlled trial.

BACKGROUND/AIMS: Endoscopic sclerotherapy is considered a first line therapy to stop bleeding from esophageal varices, but acute variceal bleeding is still associated with high risk of rebleeding and death. We compared the use of octreotide with endoscopic sclerotherapy versus sclerotherapy alone to control acute variceal bleeding and prevent rebleeding in patients with cirrhosis. METHODOLOGY: In a prospective controlled trial, 68 patients with cirrhosis and acute variceal bleeding who underwent emergency sclerotherapy were randomly assigned to receive a continuous infusion of octreotide or placebo for two days. The primary outcome measure was 7-day mortality. RESULTS: After seven days the overall mortality was 19.1%, and the proportion of patients who died in octreotide group (8 of 40, or 20%) was similar to the placebo group (5 of 28, or 17.85%; p = 0.74). Rebleeding occurred in 20.6% (14 of 68 patients), being 20% (8 of 40) in the octreotide group vs. 21.4% (6 of 28) in the placebo group (p = 0.88). The mean number of units of blood transfused after sclerotherapy was 2.05 units in the octreotide group vs. 2.08 units in the placebo group (p = 0.96). Thirty patients needed intensive care support (20 of 40 in the octreotide group vs. 10 of 28 in the placebo group; p = 0.24). The differences remained without statistical significance even after adjustment for hepatic function and endoscopic bleeding stigmata by a linear regression model analysis test. CONCLUSIONS: In patients with cirrhosis, octreotide intravenous per 48h associated with sclerotherapy is not superior to sclerotherapy alone in terms of 7-day mortality, frequency of rebleeding, number of units of packet red blood cell transfusion and length of stay in intensive care setting.

Pancreatic endoscopic sphincterotomy in patients with chronic pancreatitis: a single-center experience in 171 consecutive patients.

BACKGROUND AND STUDY AIMS: In recent years, interest in endoscopic therapy techniques for pancreatic diseases has been constantly increasing. The aim of the present study was to assess the technical success, technique, and complications of endoscopic pancreatic sphincterotomy (EPS) in patients with chronic pancreatitis. PATIENTS AND METHODS: A total of 171 patients with chronic pancreatitis and abdominal complaints were identified in whom at least one attempt at EPS was carried out. During the procedure, sphincterotomy was carried out using a guide-wire sphincterotome or a needle-knife papillotome. Patients were followed up after EPS for at least 24 h, including clinical symptoms and laboratory data (pancreatic enzymes and hemoglobin/hematocrit). RESULTS: EPS was performed in 167 of the 171 patients (technical success rate: 97.7 %). In 24 patients (14 %), a precut technique was necessary using a needle-knife sphincterotome. Sphincterotomy-related complications were observed in seven of the 171 patients (4.1 %), including three cases of bleeding, three patients with mild pancreatitis, and one with retroduodenal perforation. All complications were managed medically. There was no treatment-related mortality. CONCLUSIONS: Endoscopic sphincterotomy of the pancreatic duct in patients with chronic pancreatitis is a fairly safe procedure with a high technical success rate.

Endoscopic treatment of choledocholithiasis in the era of laparoscopic cholecystectomy: prospective analysis of 386 patients.

BACKGROUND/AIMS: Endoscopic papillotomy is a well-established procedure for treating choledocholithiasis. The aim of this study is to expose our experience with this method in a prospectively collected series of 386 patients and to analyze the safety and efficacy of the pre-cut procedure. METHODOLOGY: Between October 1995 and December 1999, 760 endoscopic retrograde cholangiopancreatographies were performed in 670 patients. Of these, 449 were done to treat 386 patients with choledocholithiasis. The pre-cut technique was performed after failure of multiple cannulation attempts. RESULTS: Bile duct clearance was achieved in 344 (89.1%) cases, however the success rate would increase to 95.1%, if the cases, which endoscopic stone extraction was not feasible, were excluded. Pre-cut was performed in 31 (8.03%) patients, and 11 of them presented some procedure-related complication, while the complication rate of standard sphincterotomy was 3.9% (relative risk = 8.4; 95% confidence interval = 4.2-16.7). Overall complication rate was 6.7% (26 out of 386)--pancreatitis = 13, bleeding = 9, acute cholecystitis = 2, cholangitis = 1, guide-wire-related choledochal perforation = 1. Thirty-day mortality was 1.55% (n = 6), but procedure-related mortality was 0.25% (n = 1). CONCLUSIONS: Endoscopic papillotomy is a safe and effective procedure for patients with symptomatic choledocholithiasis. The pre-cut procedure increases the complication rate of the endoscopic approach, and should be restricted to cases, in which an endoscopic intervention is mandatory.

Endoscopic removal of Ascaris lumbricoides from the biliary tract as emergency treatment for acute suppurative cholangitis.

Ascariasis is the most common intestinal helminthiasis worldwide. Heavily infected individuals are prone to develop bowel obstruction or perforation as well as biliary disease. Nevertheless, the presence of roundworms in the biliary tree outside endemic areas is very uncommon. The migration of these worms to the biliary system can cause biliary colic, pancreatitis, or even acute suppurative cholangitis with hepatic abscesses and septicemia. We report here on 2 infants with 14 and 15 months and a 9-year-old boy who suffered from massive biliary ascariasis and who presented with acute suppurative cholangitis. All cases were successfully treated by endoscopic retrograde cholangiopancreatography with worm extraction and adjuvant medical therapy. Physicians should be aware of ascariasis in patients with pancreatobiliary symptoms who have traveled to endemic areas or in immigrants from these areas.

Consensus and variable region PCR analysis of Helicobacter pylori 3' region of cagA gene in isolates from individuals with or without peptic ulcer.

The clinical outcome of Helicobacter pylori infection may be associated with the cagA bacterial genotype. To investigate the cagA status of H. pylori-infected patients and the relationship between cagA and peptic ulcer disease, gastric biopsy specimens from 103 Caucasian patients in Brazil were analyzed by PCR. Since allelic variation in cagA exists and distinct H. pylori subgenotypes may circulate in different regions, PCR using primers for a variable 3' region of the cagA gene according to a Japanese methodology and for a consensus cagA 3' region used in Western methods was used for cagA detection. cagA was present in 53 (71%) of 75 H. pylori-positive cases when analyzed by the consensus region method and was associated with duodenal ulcer disease (P = 0.02), but not with gastric ulcer (P = 0.26), when compared to patients with duodenitis or gastritis. The variable region PCR method was able to detect 43 (57%) cagA-positive cases within the same group of H. pylori-positive patients and showed three subtypes of cagA (A, B/D, and C) that were not associated with clinical outcome. However, in 8 (18%) of the cases, more than one subtype was present, and an association between patients with multiple subtypes and disease outcome was observed when compared to patients with isolated subtypes (P = 0.048). cagA was a marker of H. pylori strains for duodenal ulcer disease in our population, and in spite of the differences in the 3' region of the cagA gene, the Japanese methodology was able to detect the cagA status in most cases. The presence of multiple subgenotypes of cagA was associated with gastric ulcer.

The effects of allopurinol in hepatic ischemia and reperfusion: experimental study in rats.

BACKGROUND/AIMS: Some studies have shown that postischemic hepatic dysfunction is mainly due to oxygen free radicals that are generated by xanthine oxidase. The present study was undertaken to determine the effect of allopurinol, an inhibitor of xanthine oxidase, on oxidative stress, liver injury and histologic alterations induced by hepatic ischemia-reperfusion in rats. METHODS: One hundred and sixty Wistar rats were used and divided into three groups. Group 1: sham operation; group 2: 50 min of ischemia followed by 1 h of reperfusion, and group 3: pretreatment with allopurinol and 50 min of ischemia followed by 1 h of reperfusion. The effect of allopurinol was evaluated by plasma levels of alanine aminotransferase and aspartate aminotransferase, histopathologic studies, and lipid peroxidation measured by the thiobarbituric acid reactive substances method and chemiluminescence initiated by tert-butyl hydroperoxide technique. RESULTS: Ischemia followed by reperfusion promoted an increase in lipid peroxidation of the hepatic cells when compared to the sham-operated group (p<0.05). This increase was attenuated in the group treated with allopurinol (p< 0.05). Allopurinol also showed a protective effect on hepatocellular necrosis (p<0.05), and the plasma levels of liver enzymes returned earlier to the normal range in rats pretreated with allopurinol in comparison to those that did not receive the drug (p<0.05). CONCLUSIONS: Allopurinol exerted a protective effect on hepatic ischemia and reperfusion in rats. The administration of this drug prior to liver operations should be considered to be submitted to trials in humans.

High power setting argon plasma coagulation for the eradication of Barrett's esophagus.

OBJECTIVE: The term Barrett's esophagus refers to a premalignant condition that is characterized by the replacement of the esophageal squamous mucosa by a columnar-lined one. Preliminary studies have demonstrated reversal of Barrett's mucosa after endoscopic coagulation with different techniques associated with acid inhibition. However, most of these studies have shown that residual Barrett's glands are found underneath the new squamous epithelium in up to 40% of patients. The goal of our study is to verify whether complete restoration of Barrett's mucosa can be achieved by the combination of high power setting argon plasma coagulation and omeprazole. METHODS: A total of 33 patients (mean age: 55.2 yr, range: 21-84 yr; 21 men and 12 women) with histologically demonstrated Barrett's esophagus (mean length: 4.05 cm, range: 0.5-7 cm) were treated. Fourteen cases presented with low-grade dysplasia and one with high-grade dysplasia. All of the extent, or until a maximum of 4 cm, of the Barrett's mucosa was cauterized in each session using argon beam coagulation at a power setting of 65-70 W. All patients received 60 mg omeprazole during the treatment period. RESULTS: Complete restoration of squamous mucosa was obtained in all 33 cases after a mean of 1.96 sessions (range, 1-4). Endoscopic results were histologically confirmed. Nineteen (57.5%) patients experienced moderate to severe chest pain and odyno-dysphagia lasting for 3-10 days after the procedure. Five of these cases experienced high fever and a small volume of pleural effusion, and three patients developed esophageal strictures that needed to be dilated. Another patient developed pneumomediastinum and subcutaneous emphysema without evidences of perforation. After a mean follow-up of 10.6 months there was one endoscopic, as well as histological, recurrence of Barrett's mucosa in a patient with an ineffective laparoscopic fundoplication. CONCLUSIONS: High power setting argon plasma coagulation combined with intensive acid suppression is an effective treatment for the total endoscopic ablation of Barrett's esophagus, at least in the short term. Long-term follow-up of treated patients in whom gastroesophageal reflux is surgically or medically alleviated seems mandatory before drawing definitive conclusions about this therapy.

Metastasis from colon carcinoma in the dorsal pancreas of a patient with pancreas divisum: report of a case.

The authors report the case of a 45-year-old woman who suffered from epigastric pain and was operated on 3 years before for colon cancer. The clinical investigation revealed that the patient had colon cancer metastasis to the dorsal pancreas of a pancreas divisum.

The role of serum liver enzymes in the diagnosis of choledocholithiasis.

BACKGROUND/AIMS: The introduction of laparoscopic cholecystectomy has increased the need for preoperative diagnosis of common bile duct stones. The purpose of this study is to verify the sensitivity of the liver function tests in the detection of duct stones. METHODOLOGY: We evaluated 438 patients (223 retrospectively and 215 prospectively) who underwent endoscopic papillotomy for bile duct stones in two different services. In every case, blood samples for liver function tests levels were collected prior to endoscopic retrograde cholangiopancreatography. RESULTS: The most sensitive test was gamma-glutamyl transpeptidase, that was abnormal in 92.2% of the cases. Alkaline phosphatase was elevated in 74.7% of the patients with choledocholithiasis. The least sensitive parameter was AST, altered in only 50.8% of times. The sensitivity of all liver tests for the diagnosis of choledochal stones taken together was 94.3%. CONCLUSIONS: Liver function tests are very sensitive in the detection of common bile duct stones, however these blood tests are in the normal range of about 5% of endoscopically treated patients.

The role of colchicine in prevention of hepatic cirrhosis induced by carbon tetrachloride.

BACKGROUND/AIMS: The present study was undertaken to determine whether colchicine has a beneficial effect in the prevention of hepatic cirrhosis when it is given simultaneously with CCl4. METHODOLOGY: Wistar rats were employed as experimental animals and divided into 6 groups: Group I received saline solution, Group II, saline solution and mineral oil; Group III, colchicine (10 micrograms/100 g) and mineral oil; Group IV, colchicine (10 micrograms/100 g) and CCl4; Group V, colchicine (5 micrograms/100 g) and CCl4; and, Group VI received saline solution and CCl4. The effect of colchicine was evaluated by liver function tests, serum total proteins, electrolytes and histological evaluation. RESULTS: The results demonstrated higher values of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and total bilirubin in groups IV and V when compared with group VI (p < 0.05). No difference between group VI and groups IV and V was observed in histological evaluation, serum total proteins and electrolytes (p < 0.05). CONCLUSIONS: Colchicine, as given in this study, did not have any protective effect in the prevention of cirrhosis induced by carbon tetrachloride.

Endoscopic dilation of benign esophageal strictures: report on 1043 procedures.

OBJECTIVE: Endoscopic dilation is considered the best treatment for most cases of benign esophageal stricture, although the best dilation technique and the kind of stricture is the most amenable to treatment is still controversial. We report on our experience on a large series of patients treated by dilation without the aid of fluoroscopy and compare the results of this therapy among patients with strictures from different causes. METHODS: Between 1992 and 1997, we performed 1043 dilation sessions on 153 patients. Treatment was considered adequate if the esophageal lumen could be dilated up to the size of a 42F catheter. If the stricture recurred after initial successful treatment, the stricture was dilated again up to a 42F catheter. RESULTS: One hundred forty patients (96 men, 44 women; mean age, 54.1 yr) were followed-up for a mean of 20.5 months (4 to 62 months). Stricture's etiology was postsurgical in 80 patients, peptic in 37, caustic in 12, and from other causes in 11 patients. Adequate dilation was achieved in 93.5% of the patients (131 of 140). Patients with peptic strictures needed a median of three sessions to be adequately dilated during follow-up in comparison to five sessions among patients with postsurgical or caustic strictures (p = 0.07). There were four perforations, with one death (2.8% and 0.7% per patient and 0.4% and 0.1% per session, respectively). CONCLUSIONS: Endoscopic dilation without the aid of fluoroscopy is safe and effective in relieving dysphagia caused by benign strictures of different causes, although repeated sessions are necessary because of stricture recurrence.

Pancreatic fistula after pancreaticoduodenectomy: a comparison between patients with periampullary tumors and chronic pancreatitis.

BACKGROUND/AIMS: Whether the frequency of anastomotic leak after pancreaticoduodenectomy for benign diseases is greater than for malignant conditions and whether fistula development is associated with surgical mortality remains controversial. The purpose of this study is to compare the incidence of anastomotic leak in patients operated on for chronic pancreatitis and periampullary tumors. METHODOLOGY: The authors retrospectively reviewed the charts of 67 patients (46 males, 21 females, mean age 47 years) submitted to pancreaticoduodenectomy for chronic pancreatitis and periampullary tumors between 1990 and 1996. RESULTS: In 44 patients with periampullary cancers, pancreatic fistula developed in 13 (29%) cases, and in 6 (26%) of the 23 patients with chronic pancreatitis (p>0.05). Of the 19 patients who developed this complication, 5 (26.3%) died, and in the remaining 48 cases, there was only one (2.1%) death (p<0.05). CONCLUSION: The frequency of pancreatic fistula after pancreaticoduodenectomy in patients with periampullary tumors and chronic pancreatitis is not different, but the presence of a fistula is strongly involved in postoperative mortality.

Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms.

BACKGROUND: The long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms. METHODS: Between 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients' relatives and general practitioners. RESULTS: The procedure was successful in 217 of 223 cases (97%), of which 203 were followed-up; 2 patients died in the first month after treatment (0.89%). Mean follow-up for the 201 patients was 6.2 years, during which 31 relapsed (15%). Three significant prognostic factors for late complications were identified in a multivariate analysis. The recurrence rate of biliary symptoms in patients who were left with an in situ gallbladder was 20.2%, and 11% for those whose gallbladder was removed (p = 0.04). Patients with a bile duct 15 mm or greater in diameter were more prone to recurrence of symptoms than those with a bile duct 10 mm or less in diameter (41% vs. 10%, p = 0.025) and were especially at higher risk to develop recurrent stones (19.5% vs. 4.9%, p = 0.019). Stone recurrence, but not biliary symptoms as a whole, was more frequent in patients with a peripapillary diverticulum (p = 0.035). CONCLUSIONS: The long-term results of endoscopic papillotomy are comparable with those of surgical techniques. The prognostic factors associated with relapse of biliary symptoms as a whole are gallbladder left in situ and choledochal diameter. Bile duct size and peripapillary diverticula are associated with recurrent bile duct stones.

Endoscopic biliary stenting for the palliation of pancreatic cancer: results, survival predictive factors, and comparison of 10-French with 11.5-French gauge stents.

OBJECTIVES: To compare the efficacy and complications of different stent lengths and diameters in the palliation of jaundice caused by pancreatic cancer, as well as investigate survival predictive factors and the success of endoscopic therapy. METHODS: This study summarizes our results with 103 pancreas cancer patients treated by endoscopic plastic biliary stenting, of whom 87 were followed up until death or the time of writing. Before therapy, bilirubinemia, tumor primary size, presence of distant metastases, and signs of duodenal involvement were evaluated as prognosis risk factors. In a retrospective, nonrandomized fashion, we compared the efficacy and complications (especially clogging) of 10-French versus 11.5-French gauge stents and of "short" (< or = 8 cm) versus "long" (> or = 9 cm) prostheses. RESULTS: Thirty six men and 51 women (median age 74 yr) with pancreatic cancer were analyzed. Stenting could abolish jaundice or make it imperceptible (bilirubinemia < 3 mg %) in 74 patients (85%). Median bilirubinemia after treatment decreased from 13.9 mg/dl to 1.0 mg/dl. Hospital mortality was 2.7%. The commonest long term complication was clogging, which occurred 66 times in 33 patients. Median stent patency was 3 and 4 months for 10-F gauge and 11.5-F gauge stents, respectively (p > 0.05). When analyzing the patients who were alive 6 months after therapy, the clogging rate was 46% and 55% for 10-F and 11.5-F stents, respectively (p > 0.05). The length also did not influence stent patency. The only risk factor assessed before therapy, which independently predicted survival, was the presence of distant metastases. Median survival for patients with metastatic disease was 2.5 months and 9 months for those without metastases (p = 0.0015). CONCLUSIONS: We conclude that 10-F and 11.5-F stents have the same efficacy in the palliative management of malignant obstructive jaundice due to cancer of the pancreas. Detection of distant metastases is the best outcome predictive factor in these patients and should be regarded as a restriction to the insertion of biliary metal stents.

Endoscopic stenting in obstructive jaundice due to liver metastases: does it have a benefit for the patient?

BACKGROUND/AIMS: The goal of this report is to describe our experience with the palliative endoscopic treatment of jaundice occurring in the setting of liver and hilar metastases of a distant primary malignancy. MATERIAL AND METHODS: We retrospectively analyzed the clinical course of 29 consecutive patients with metastatic tumors not originating in the hepatobiliopancreatic area, who were treated by endoscopic retrograde cholangiopancreatography with endoprostheses insertion. RESULTS: We achieved a complete follow-up in 24 out of the 29 patients (11 women, median age 69 years). The primary tumor site was the colorectum in 15 patients, stomach in 4, lung in 2, breast and prostate in 1 and one patient had a lymphoma. The median bilirubinemia before therapy was 16 (1.8-31) mg/dl and the median minimum serum bilirubin reached after stenting was 2.6 (0.3-11.5) mg/dl. Stent dysfunction was observed in 33.5% of the patients and stent change was necessary 13 times. The median survival after therapy was 4 (2.5-19) months for patients with colon tumors and 3 (0.5-12) months in patients with other cancers. An improvement in the quality of life was obtained in 75% of the patients after endoscopic treatment. CONCLUSIONS: Endoscopic stenting should be attempted even on patients with obstructive jaundice due to liver metastases.

Cholestatic jaundice due to Ormond's disease (primary retroperitoneal fibrosis).

A case of a 51-year-old man, who presented with cholestatic jaundice due to common bile duct compression produced by primary retroperitoneal fibrosis, is reported. The patient was operated on two years earlier because of hydronephrosis, when the disease was diagnosed. Cholangiopancreatography revealed a "double duct sign", disclosing another benign cause for this radiographic sign, that once was considered to be pathognomonic of pancreas cancer. The bile duct stricture was managed by the insertion of an endoscopic endoprosthesis. This is the first report of jaundice due to Ormond's disease and the third, due to retroperitoneal fibrosis.

[Endoscopic laser lithotripsy for difficult calculi after unsuccessful extracorporeal shock wave lithotripsy]. / Litotripsia endoscópica à laser em cálculos difíceis não responsivos à litotripsia extracorpórea por ondas de choque.

INTRODUCTION: More than 97% of common bile duct stones can be successfully managed by endoscopic papillotomy, mechanical lithotripsy and extracorporeal shock-wave lithotripsy. In this study, we evaluate the role of laser lithotripsy after failure of the above mentioned endoscopic methods. PATIENTS AND METHODS: Eighteen patients (15F, 3M; median age = 69 (28-83) years) were treated by endoscopic laser lithotripsy after ESWL failure. We employed a Rhodamine-6 G laser with a stone-tissue recognizing system. The laser fibers were cholangioscopically (direct vision) or blindly (under plain fluoroscopic control) placed. RESULTS: Seventeen patients were treated endoscopically and one was successfully managed percutaneously after failure of the transpapillary approach. Fourteen (78%) were stone-free after a mean of 1.56 laser therapy sessions alone. Two additional patients were successfully managed after partial fragmentation with combined treatment (mechanical lithotripsy: n = 1, electrohydraulic lithotripsy: n = 1). Overall, 89% of the patients were freed from their calculi. Cholangitis occurred once and the mortality was zero. CONCLUSIONS: We conclude that laser lithotripsy is an effective and safe treatment alternative in a highly selected patient population with difficult bile duct stones and considerable surgical risk.