A prospective study on the value of ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography in the diagnosis of unjaundiced cholestasis.

The purpose of this study was to investigate the diagnostic accuracy of ultrasound (US), computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the distinction between extrahepatic and intrahepatic causes of unjaundiced cholestasis. Moreover, attention was paid to the ability of these methods to distinguish between benign and malignant causes of obstruction. The inclusion criteria of laboratory values suggesting cholestasis were serum alkaline phosphatase 350 U/l and gammaglutamyl transpeptidase 100 U/l or liver-specific alkaline phosphatase elevated. The diagnostic value of the imaging methods was tested in 33 patients. The most common cause of unjaundiced obstruction was choledochal stone disease. The diagnostic sensitivities of US, CT and ERCP for the detection of extrahepatic cholestasis were 53%, 53% and 79%, respectively. In patients on whom all three imaging studies were done (n = 20), the difference between US and ERCP was statistically significant (p > 0.05). The specificities of US, CT and ERCP were 100%, 86% and 90%, respectively. CT was better than US in defining the benign nature of obstruction, but ERCP was superior in this respect. In malignant obstructions CT was comparable to ERCP. In conclusion, ERCP seems to be considerably sensitive for the detection of extrahepatic obstruction in cases of unjaundiced cholestasis, whereas US and CT are rather insensitive. The specificity of all these imaging methods is high. The results are in favour of CT as the best noninvasive investigation method, and also indicate the important role of ERCP. However, in many cases all three imaging methods are needed, and a flexible and complementary use of them is recommended.

Chronic critical lower-limb ischemia: prospective trial of angioplasty with 1-36 months follow-up.

To determine the utility of percutaneous transluminal angioplasty (PTA) in the treatment of chronic critical lower-limb ischemia, a prospective study of 103 consecutive patients (117 limbs) was performed. Patients underwent PTA for a total of 209 lesions in the iliac (n = 4), femoropopliteal (n = 121), and infrapopliteal (n = 84) arteries and were followed up for 1-36 months (mean, 12 months). The primary technical success rate was 92% for stenosis and 80% for occlusion. Survival analysis with the Kaplan-Meier method revealed 1-, 2-, and 3-year limb salvage rates of 56%, 49%, and 49%, respectively. The following factors correlated favorably with limb salvage in Cox multiple regression analyses: a small number of diseased lower-limb vessels (one to five vs six to eight) and treated lesions per limb (one or two vs three to five), achieved peripheral runoff (one to three patent calf vessels vs none), and an occlusion as the successfully treated target lesion (instead of stenosis).

A comparison of ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography in the differential diagnosis of benign and malignant jaundice and cholestasis.

OBJECTIVE: To assess the accuracy of ultrasonography (US), computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) in distinguishing between benign and malignant causes of jaundice and cholestasis without jaundice. DESIGN: Prospective study. SETTING: University Hospital in Finland. SUBJECTS: A consecutive series of patients with jaundice (n = 187) or cholestasis without jaundice (n = 33). MAIN OUTCOME MEASURES: Correlation between diagnosis on imaging and final diagnosis at follow up 6 months later. Final diagnoses made on histology (n = 79), cytology (n = 5), operative or endoscopic findings (n = 96), and clinical course or serology (n = 40). RESULTS: The most common benign disease was choledocholithiasis (n = 83) and the most common malignant disease was carcinoma of pancreas (n = 33). The benign nature of the extrahepatic obstruction was correctly defined by US, CT, and ERCP in 53%, 53%, and 90% of patients, respectively, and the corresponding figures for choledocholithiasis were 22%, 25%, and 79% (ERCP compared with each of the other techniques, p < 0.0001). Intrahepatic benign diseases were diagnosed by US and CT in a third of cases. Malignant extrahepatic obstruction was correctly diagnosed in 57%, 80%, and 83%, respectively and the corresponding figures for pancreatic cancer were 60%, 97%, and 89% (US compared with CT, p < 0.01, and with ERCP, p < 0.05). Intrahepatic malignant lesions were diagnosed by US, CT, and ERCP in 100%, 77%, and 60% of patients, respectively. CONCLUSIONS: When the obstruction was benign and extrahepatic ERCP was the most accurate, but when it was malignant CT was comparable. Intrahepatic disease was best diagnosed by US and CT. The results emphasise that the three methods of imaging are complementary.

The value of clinical assessment in the diagnosis of icterus and cholestasis.

We studied the reliability of the clinical assessment and the discriminatory value of different symptoms and signs in diagnosing obstructive and non-obstructive diseases causing icterus and/or cholestasis. During a period of two-and-a-half years, clinical assessment done by both physicians-in-training and by senior physicians was completed for 266 patients, and the usefulness of different symptoms and signs was tested in 220 of these. Clinical assessment was found to be a reliable method in distinguishing between obstructive and non-obstructive conditions causing icterus, with the sensitivity of 92% and specificity of 86%. In cases of anicteric cholestasis, the sensitivity and specificity of clinical assessment were 74% and 80%, respectively. Abdominal pain and abdominal tenderness were significantly (p less than 0.01) associated with obstructive diseases, whereas an enlarged liver, fever and excessive consumption of alcohol were associated with non-obstructive diseases (p less than 0.01, p less than 0.05, p less than 0.05, respectively). Itching, vomiting, intolerance to fatty foods, previous cholecystectomy, abdominal tumour and clinical icterus had no discriminatory value. Clinical evaluation is a reliable method in the diagnostic workup of a patient with icterus or anicteric cholestasis, and it is still of crucial importance in directing further investigations.

Diagnostic accuracy of ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography in the detection of pancreatic cancer in patients with jaundice or cholestasis.

A prospective study of jaundiced and/or cholestatic patients (N = 220) was carried out to evaluate the diagnostic accuracy of ultrasound (US), computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of pancreatic cancer. Thirty-one patients had the final diagnosis of pancreatic cancer and two patients had a cancer of the papilla of Vater. The sensitivities of US, CT and ERCP were 60%, 97%, 89% and specificities were 92%, 92%, 94%, respectively. The differences in sensitivity between US and other methods were statistically significant (US vs. CT p less than 0.01, US vs. ERCP p less than 0.05). In US studies, most false negative results were caused by unsatisfying visualization. On the basis of this study, we recommend CT as a diagnostic test of pancreatic cancer, if pancreatic cancer is suspected as a cause of jaundice and/or cholestasis.

Complications of endoscopic retrograde cholangiopancreatography in jaundiced and cholestatic patients.

The purpose of this prospective study was to investigate the complication rate of endoscopic retrograde cholangiopancreatography (ERCP) in the management of jaundiced and unjaundiced patients with laboratory findings suggesting cholestasis. ERCP was performed in 144 jaundiced patients and in 27 patients with unjaundiced cholestasis (age range 18-89 years, mean 66 years). Endoscopic papillotomy was performed in 45 patients, three for spasm of the sphincter of Oddi and the rest for choledochal stones. Seven bile duct prostheses were inserted endoscopically, all for treatment of malignant obstruction. The complications of ERCP were as follows: four cases of pancreatitis (2.3%), five cases of cholangitis (2.9%), two cases of bleeding (1.2%) and two perforations (1.2%). The overall complication rate was thus 7.6% (13/171) and there was no primary mortality. ERCP seems to be a safe and effective method in the diagnostic study and management of bile duct obstruction even in the elderly patients with jaundice or unjaundiced cholestasis.

Ultrasonography, CT, and ERCP in the diagnosis of choledochal stones.

A prospective study of jaundiced (n = 187) and nonjaundiced (n = 33) cholestatic patients was carried out to evaluate the sensitivity of ultrasonography (US), CT, and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of choledochal stone disease. Altogether 83 patients had the final diagnosis of choledocholithiasis. In the jaundiced patients, the sensitivity of US, CT, and ERCP was 22.5%, 23.2%, and 80.6%, respectively. In cases of cholestasis without jaundice, the values were 20%, 37.5%, and 66.7%. In patients in whom all 3 imaging studies were done (n = 64), the differences between US and ERCP and between CT and ERCP were statistically significant (p less than 0.0001). In most false-negative ERCP studies (10/15), the clinical course of the disease strongly suggested a passed choledochal stone. On the basis of this study, we recommend prompt ERCP to be performed if choledochal stone disease is suspected on clinical grounds.

Diagnostic accuracy of ultrasound, computed tomography, and endoscopic retrograde cholangiopancreatography in the detection of obstructive jaundice.

The purpose of this prospective study was to investigate the diagnostic accuracy of ultrasound (US), computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) in the distinction between extrahepatic and intrahepatic causes of jaundice. The limit for the inclusion to the study was defined as a serum bilirubin concentration greater than or equal to 40 mumol/l. Altogether 187 jaundiced patients were studied. The sensitivities of US, CT, and ERCP were 63%, 77%, and 87%, respectively. The differences between all these methods were statistically significant. The specificities and positive predictive values were high, reaching 96-99%, but the negative predictive values were low, ranging between 38% and 60%. Choledochal stone disease constituted the main etiology of false-negative studies in all investigations. Imaging procedures have a prominent role in the diagnostic study of the jaundiced patient, but it is obvious that their diagnostic accuracy may vary between institutions because of the variance in local experience and expertise, and because of the differences in diseases causing jaundice.

Radiological evaluation of the acromioclavicular joint.

X-ray measurement of the acromioclavicular (AC) joint may cause difficulties because of different projections and the lack of a reproducible measurement. In order to find the ideal measurement to estimate the state of the AC joint, 28 healthy adult volunteers were X-rayed. The least vulnerable measurement for errors in projection was the distance between the coracoid process and the upper part of the clavicle. The effect of stress was evaluated; the range of normal AC joint laxity was determined as 3 mm.

Digitalised endoscopic retrograde pancreatography (D-ERP): a comparison with ERCP.

Cannulation of the papilla of Vater was successful in 49 out of 65 cases (75.4%) and digital imaging of the pancreas in 38% of cases. Visualisation of the pancreatic duct with D-ERP was comparable to that of conventional ERCP. Absent or faint opacification of the parenchyma was seen in 39.5% of patients. Both methods were equally effective for the diagnosis of pancreatic tumours. D-ERP was better than ERCP for the diagnosis of chronic pancreatitis. Two patients (4.1%) had clinical evidence of mild acute pancreatitis following pancreatic duct injections.

Selenium levels in whole blood of Finnish volunteers before and during organic and inorganic selenium supplementation.

High selenium barley biscuits containing 1 mumol (70 micrograms) organic Se were administered to healthy male volunteers for 5 weeks at doses of 2.1 mumol Se (group A) or 6.4 mumol (group B). In addition, 2 mg Na-selenate capsules (5.4 mumol Se) were given to two other groups at daily doses of 2 mg (group C) or 8 mg (group D). Groups A, B and C each comprised eight healthy men and group D eight healthy women and three men. The initial median concentration of whole blood selenium (B-Se for groups A, B and C were 1.0-1.1 mumol/l (range 0.7-1.7) and for group D 1.3 mumol/l (range 0.9-1.8). In 1-2 weeks time the B-Se concentrations rose to 1.6 mumol/l for groups A and C, to 1.8 mumol/l for group B, and to 2.2 mumol/l for group D. There was no decrease 1 week after the Se intake ceased. As expected, the level of B-Se increased more (in relation to dose) in those given organic Se than in those given inorganic Se. Groups A, B and C, however, had rather moderate increases. The daily dose required to raise the B-Se of Finns up to the North American level (2.2 mumol/l) was as high as 8 mg Na-selenate (21.5 mumol or 1700 micrograms Se), but the dose of organic Se which would be required to achieve this level is not yet known.