Diagnostic laparoscopy.

Diagnostic laparoscopy continues to play an important role in the accurate evaluation of patients with abdominal disorders. Combined with laparoscopic ultrasound, it is highly accurate in the staging of intra-abdominal malignancies, and it is superior to transcutaneous ultrasonography and computed tomography. Other important applications include the evaluation of patients with acute and chronic abdominal pain, acute abdomen, peritonitis, and blunt and penetrating abdominal trauma. Laparoscopy now rests firmly in the hands of surgeons. The majority of last year's papers originated from departments of surgery; papers on laparoscopy in hepatic disorders are sorely missing in this year's review.

Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: extended follow-up of an expanded randomized prospective trial.

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a "bridge to transplantation." All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child's class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P < 0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P < 0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P < 0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding.

Liver biopsy: review of methodology and complications.

Liver biopsy remains an essential tool to confirm a suspected diagnosis and guide specific therapy in patients with liver disease. The methods available to obtain liver tissue include percutaneous needle biopsy, transjugular biopsy, image-guided needle biopsy, and laparoscopic direct vision guided needle biopsy. Advantages and disadvantages of each modality are reviewed herein. The indications for liver biopsy include evaluation of elevated aminotransferases, assessment of response to therapy of chronic liver disease, monitoring for hepatoxicity of drug therapy, and liver transplant allograft evaluation. Contraindications include impaired coagulation, significant ascites, high-grade extrahepatic biliary obstruction, echinococcal cyst, and certain anatomic abnormalities. Complications include pain, hemorrhage, bile peritonitis, penetration of abdominal viscera, pneumothorax, and death. Complications are reported in 0.06-0.32% of the patients. Death as a direct result of liver biopsy is extremely rare (0.009-0.12%). In properly selected patients, liver biopsy has a high benefit/risk ratio and is often considered the final and definitive diagnostic test.

Significance of solitary and multiple esophageal ulcers in patients with AIDS.

We endoscopically evaluated odynophagia and/or dysphagia in 23 patients with acquired immunodeficiency syndrome (AIDS). Eleven patients (48%) were found to have esophageal ulcers. Seven of them had deep, sharply demarcated, well-circumscribed ulcer craters with raised edges; in two the ulcer extended to the muscularis propria. Ulcers were single in four patients, multiple in six, and unspecified in one. Biopsies were nondiagnostic. In eight patients, mycobacterial, viral, and fungal cultures were negative. Specific infections diagnosed in three patients were treated with appropriate agents. Ulcers were treated symptomatically, and seven patients received therapy for suspected viral etiology. Symptoms remained unchanged in five patients, improved in three, and resolved in two. Fifty-five percent of patients died within 3.6 months (mean) of diagnosis. Large solitary and multiple esophageal ulcers are common in AIDS patients with odynophagia and dysphagia.

Non 0-1 Vibrio cholerae septicemia and culture negative neutrocytic ascites in a patient with chronic liver disease.

Non 0-1 Vibrio cholerae infection is often associated with ingestion of contaminated seafood and its common presentation is gastroenteritis. Septicemia may be found in immunocompromised hosts resulting in mortality approaching 50%. A case is reported of non 0-1 Vibrio cholerae infection presenting with septicemia in a patient with neutrocytic ascites suggestive of spontaneous bacterial peritonitis.

Endoscopic diagnosis and treatment of esophageal cancer.

Esophageal carcinoma is one of the deadliest malignant tumors. This article reviews its epidemiology, etiology, and clinical and endoscopic presentation, as well as methods for proper staging to identify the patients who will not benefit from surgery and require palliative therapy. The various treatment options are discussed in detail with an emphasis on the latest endoscopic palliative measures.

Niacin-induced hepatotoxicity: unusual presentations.

We report four cases of niacin-induced hepatotoxicity. All four patients were using sustained-release niacin preparations. When they stopped taking niacin, symptoms and laboratory abnormalities resolved. Two of the patients had focal fatty infiltration of the liver on imaging studies, a presentation of niacin hepatotoxicity not previously described. One patient had a coagulopathy even though aminotransferase levels were only mildly elevated. We recommend that patients using sustained-release preparations of niacin have periodic monitoring of liver enzymes and that the preparation be discontinued if any abnormalities develop.

Are hyperplastic rectosigmoid polyps associated with an increased risk of proximal colonic neoplasms?

Diminutive polyps are frequent findings on screening flexible sigmoidoscopy. To determine the significance of distal diminutive polyps, we conducted a prospective study of 162 asymptomatic, average-risk subjects who were 50 years of age or older. Subjects were divided into four groups: 42 control subjects with no polyps in the rectosigmoid, 66 subjects with at least one diminutive adenoma in the rectosigmoid, 12 subjects with a mixed hyperplastic-adenomatous polyp in the rectosigmoid, and 42 subjects with only hyperplastic polyps in the rectosigmoid. Total colonoscopy was performed on all subjects. The prevalence of proximal adenomas was 42% in the adenoma group, 25% in the mixed group, 14% in the hyperplastic group and 12% in the control group. The prevalence of proximal adenomas was significantly higher (p = 0.006) in the adenoma group as compared with the control and hyperplastic groups. Increasing age was associated with an increased prevalence of proximal adenomas. Nearly two thirds of those over 65 years of age with distal diminutive adenomas had proximal colonic neoplasms. These results indicate that diminutive rectosigmoid adenomas are good markers for proximal neoplasms. Rectosigmoid hyperplastic polyps are not associated with an increased prevalence of proximal neoplasms. Total colonoscopy is not indicated if hyperplastic polyps are the only finding on flexible sigmoidoscopy.