Paraduodenal hernia: a treatable cause of upper gastrointestinal tract symptoms.

Paraduodenal hernia (PDH) is an unusual condition that is caused by congenital intestinal malrotation. Noncatastrophic presenting symptoms and their responses to surgery have not been well-characterized. Barium upper gastrointestinal (UGI) series and small bowel follow-up x-rays, performed from December 1995 to September 1996, were sequentially reviewed by one radiologist (J.M.) to identify patients with small bowel series compatible with a PDH. Case histories were reviewed for symptomatic presentation, associated evaluation, and treatment. Based on the 294 UGIs and small bowel follow-throughs performed during this 10-month period, 6 cases were suspected to have a PDH. A right PDH was confirmed in the three patients who underwent surgical exploration (prevalence 1%). Preoperative patient symptoms included nausea, bilious vomiting, and right upper quadrant pain. Repair of the hernia defect resulted in complete resolution of chronic symptoms. Preoperative upper endoscopy, performed in three patients, was not helpful in identifying the disorder. Preoperative computerized tomography obtained in two patients was diagnostic for a right PDH. One symptomatic patient with vomiting and gastric stasis did not have surgery because of a terminal illness. The remaining two patients had no symptoms attributable to PDH. Patients with PDH frequently have chronic UGI symptoms. An upper endoscopy cannot be used to exclude this entity. After surgery, UGI symptoms from PDH are likely to resolve.

Biliary stricture measurement and stent selection.

OBJECTIVE: Because of variations in magnification, errors in stent selection may occur when stricture location is determined from fluoroscopic images or x-ray film. METHODS: An ERCP catheter with measurement markings was inserted 5, 7, and 10 cm into the bile duct in 30 patients without bile obstruction. Film measurements obtained at each depth were converted to actual distances using standard conversion as well as endoscope ratio conversion formulas. The site of obstruction in 52 patients with an obstructing lesion was measured with a ruled catheter, by a wire withdrawal technique, and using x-ray film. After a stent was selected on the basis of the catheter measurement, the accuracy of stent selection was determined for each method of measure. RESULTS: Conversion of x-ray measurements to ruled catheter measurements obtained by insertions of 5, 7, and 10 cm using standard conversion factors yielded measurements of 4.9 +/- 0.9, 6.8 +/- 0.3, and 9.5 +/- 1.9 cm, respectively, with a correlation coefficient of r = 0.80. Ratio conversion yielded measurements of 0.5 +/- 0.8, 7 +/- 1.0, and 9.9 +/- 1.4, respectively, with a correlation coefficient of r = 0.88. Measurement of stricture location with the ruled catheter and then by wire withdrawal yielded a correlation coefficient of 0.98. When ruled catheter measurements were compared with the x-ray ratio conversions, the concordance dropped to 0.79. The ruled catheter and wire withdrawal were more accurate in predicting the location of the stent tip than x-ray film measurements (p < 0.001, Wilcoxon matched pairs). Of 52 stents selected, no errors in stent selection occurred when the ruled catheter was used (p < 0.001, Fisher's exact test), two errors occurred when wire withdrawal was used (p < 0.004), and 14 errors occurred when film measurements were used. CONCLUSIONS: Use of a ruled catheter or wire withdrawal is much more accurate for selecting stents than use of x-ray film measurements.

Primary non-Hodgkin's lymphoma of the common bile duct.

Primary non-Hodgkin's lymphoma of the common bile duct is rare. To date, nine cases have been recorded in the literature. We report an additional case of a 39-yr-old woman presented with obstructive jaundice. Pathological studies of the surgical specimen disclosed that the wall of the common bile duct was transmurally infiltrated by non-Hodgkin's lymphoma of diffuse large cell type of B-cell lineage intimately associated with reticular fibers. The patient received postoperative brachytherapy, followed by six cycles of chemotherapy according to the CHOP regimen. There is no evidence of lymphoma recurrence 13 months after the surgery. Our analysis of the reported cases indicates that common bile duct non-Hodgkin's lymphoma is a rapidly progressive disease, terminating in death within a year. A complete surgical resection of the lymphoma followed by chemotherapy has shown a promising result.

Consistent improvement in sphincterotome orientation with manual grooming.

BACKGROUND: During ampullary cannulation with standard sphincterotomes, wire orientation is frequently to the right of 0 and can not always be rotated to the 12 o'clock ideal. It is not known if the presence of a wire guide alters a sphincterotome's orientation or if grooming in a standardized manner improves the orientation in the majority of cases. METHODS: The intra-ampullary range of orientation of a double channel sphincterotome was prospectively evaluated before and after catheter grooming in 25 patients undergoing ERCP. The range of orientation was also measured with and without an indwelling biliary wire guide in 14 cases. RESULTS: The maximal right orientation of the untrained sphincterotomes was 35 +/- 16 degrees; with a wire guide it was 33 +/- 22 degrees. Maximal left orientation was 17 +/- 16 degrees, wire guided it remained 19 +/- 14 degrees. Manual grooming shifted the mean maximal left orientation of the sphincterotomes to -37 +/- 28 degrees (p < 0.0001), permitting 80% of groomed sphincterotomes to achieve a 0 (12 o'clock) orientation and 100% to orient 10 degrees or less from zero. CONCLUSIONS: The presence of the wire guide did not alter the orientation of the sphincterotome. Because manual grooming reliably improved the orientation of double-channel sphincterotomes, it should be routinely performed before their use.

Santorinicele as a cause of chronic pancreatic pain.

The role pancreas divisum plays in recurrent pancreatitis and chronic pancreatic pain remains controversial. When pancreatic disease does occur secondary to pancreas divisum, the pathogenesis is thought to be stenosis of the accessory duct with a resulting increase in ductal pressure. A case is reported in which stenosis of the accessory papilla orifice is thought to be responsible for cystic dilatation of the terminal portion of the duct of Santorini in a patient with pancreas divisum. This resulted in chronic pancreatic pain that resolved after sphincterotomy of the accessory papilla.

Management of carcinoma of the esophagus.

The majority of patients with esophageal carcinoma present with dysphagia. The selection criteria and the staging of patients for potential curative resection as well as endoscopic therapeutic options for palliation of this symptom are discussed. The West Virginia University experience has included 14 cases treated with surgical resection and 20 cases treated with laser photoablative therapy. Concurrent radiation and/or chemotherapy have been used in many of the patients.

Reversible decerebrate posturing secondary to hypoglycemia.

Two cases of decerebrate posturing that resolved following the administration of dextrose are reported. The literature on hypoglycemia-induced neurologic deficits is reviewed and an explanation for the quick remission of the decerebrate posturing is postulated.

Fungal infection of prosthetic joints: a report of two cases.

Two cases of yeast infection of prosthetic joints, caused by Torulopsis glabrata and Candida albicans are described. One case occurred 27 months after joint insertion. Neither patient had an underlying illness predisposing them to infection. Removal of the prosthetic device appears necessary for cure of such infection.