RESUMEN
BACKGROUND: To study in a phase I-II trial the maximum tolerated dose, the toxicity, and the tolerance of adding radiotherapy to systemic chemotherapy administered preoperatively in patients with locoregionally advanced gastric adenocarcinoma. PATIENTS AND METHODS: Patients with adenocarcinoma of the stomach (T(3)(-)(4)N(any) or T(any)N+), performance status =1, normal hematological, hepatic and renal functions received two cycles of cisplatin 100 mg/m(2) on day 1, 5-FU 800 mg/m(2) on days 1 to 4 and leucovorin 60 mg b.i.d. on days 1 to 4 q3w, concomitantly with radiation therapy escalated in three dose tiers (31.2, 38.4 and 45.6 Gy). RESULTS: Nineteen patients were accrued and 18 completed neoadjuvant therapy. Major toxicity consisted of grade 3/4 leucopenia and mucositis in 89% and 36% of the patients, respectively. Only one episode of febrile neutropenia was recorded. Dose level number 2 (38.4 Gy) with the chemotherapy given q4w is the recommended dose level. All patients were subsequently operated and no fatalities occurred. Pathological assessment showed one complete and eight partial responses. Two- and 3-year relapse-free survival rates were 57% and 50%, respectively. Only one patient relapsed locally. The peritoneum was the most frequent site of relapse. CONCLUSIONS: This neoadjuvant therapeutic program is relatively well tolerated, does not seem to increase the operative risk, and might increase the locoregional control of the disease. The frequency of peritoneal involvement in relapsing patients underscores the need for a more effective systemic treatment.
Asunto(s)
Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/radioterapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Gástricas/tratamiento farmacológico , Neoplasias Gástricas/radioterapia , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Cisplatino/administración & dosificación , Terapia Combinada , Humanos , Leucovorina/administración & dosificación , Dosis Máxima Tolerada , Terapia Neoadyuvante , Estadificación de Neoplasias , Tasa de SupervivenciaAsunto(s)
Colon/irrigación sanguínea , Hemorragia Gastrointestinal/etiología , Hipertensión Portal/complicaciones , Várices/complicaciones , Colonoscopía , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/diagnóstico , Esofagoscopía , Hemorragia Gastrointestinal/diagnóstico , Humanos , Hipertensión Portal/diagnóstico , Mucosa Intestinal/patología , Cirrosis Hepática Alcohólica/complicaciones , Cirrosis Hepática Alcohólica/diagnóstico , Masculino , Persona de Mediana Edad , Várices/diagnósticoRESUMEN
PURPOSE: To evaluate the accuracy of magnetic resonance (MR) cholangiopancreatography for detecting bile duct calculi and stenosis. MATERIALS AND METHODS: At MR cholangiopancreatography, 108 patients suspected of having bile duct calculi or stenosis were examined with two-dimensional fast spin-echo MR sequences and respiratory gating. On the basis of findings at surgery and/or intraoperative, endoscopic retrograde, and/or percutaneous cholangiography, final diagnoses were normal bile ducts (n = 38), choledocholithiasis (n = 23), Mirizzi syndrome (n = 3), benign or malignant bile duct stenosis (n = 40), choledochal cyst (n = 1), and bile duct dilatation without calculi or stenosis (n = 3). MR cholangiopancreatographic images were analyzed retrospectively by three reviewers who were unaware of final diagnoses. RESULTS: Choledocholithiasis was diagnosed with a sensitivity of 88%-92% and a specificity of 91%-98%. False-negative readings occurred because small or impacted calculi at the distal common bile duct or ampulla were difficult to detect or distinguish from stenosis. Bile duct stenosis was diagnosed with a sensitivity of 93%-100% and a specificity of 98%. Presence or absence of bile duct abnormality was assessed with a sensitivity of 97%-99% and a specificity of 95%-97%. Interobserver agreement was very good (kappa = 0.86-0.96). CONCLUSION: With MR cholangiopancreatography, bile duct calculi and stenoses can be diagnosed with high accuracy and good interobserver agreement.
Asunto(s)
Colestasis/diagnóstico , Cálculos Biliares/diagnóstico , Imagen por Resonancia Magnética , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de los Conductos Biliares/diagnóstico , Conductos Biliares/patología , Preescolar , Colestasis/etiología , Constricción Patológica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sensibilidad y EspecificidadRESUMEN
The objective of this article is to review technical aspects, discuss potential clinical indications for MR cholangiopancreatography (MRCP) and demonstrate the spectrum of diagnostic findings in benign, postoperative, and malignant conditions. We describe our current imaging protocol in comparison with other available techniques. Using a non-breath-hold, heavily T2-weighted fast-spin-echo (FSE) sequence with or without respiratory gating we obtained coronal and axial source images and maximum intensity projections (MIPs) in 102 patients with suspected abnormalities of the biliary or pancreatic ducts. Based on this series we demonstrate the diagnostic appearance of a variety of benign, postoperative, and malignant conditions of the biliary and pancreatic ducts and discuss potential clinical indications for MRCP. The non-breath-hold FSE technique enables a consistent image quality even in patients who cannot cooperate well. Respiratory gating increased the rate of diagnostic examinations from 79 to 95 %. Acquisition of coronal and axial source images enables detection of bile duct stones as small as 2 mm, although calculi that are impacted and not surrounded by hyperintense bile may sometimes be difficult to detect. The MIP reconstructions help to determine the level of obstruction in malignant jaundice, delineate anatomical variants and malformations, and to diagnose inflammatory conditions, e. g., sclerosing cholangitis, the Mirizzi syndrome and inflammatory changes in the main pancreatic duct. The MRCP technique also correctly demonstrates the morphology of bilio-enteric or bilio-biliary anastomoses. Because MRCP provides sufficient diagnostic information in a wide range of benign and malignant biliary and pancreatic disorders, it could obviate diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in many clinical settings. The ERCP technique may be increasingly reserved for patients in whom nonsurgical interventional procedures are anticipated.
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Enfermedades de las Vías Biliares/diagnóstico , Sistema Biliar/patología , Imagen por Resonancia Magnética , Enfermedades Pancreáticas/diagnóstico , Conductos Pancreáticos/patología , Humanos , Imagen por Resonancia Magnética/métodos , Páncreas/patologíaAsunto(s)
Endoscopía del Sistema Digestivo/métodos , Pancreatitis/terapia , Enfermedad Aguda , Colestasis Extrahepática/etiología , Humanos , Cuidados Paliativos , Quiste Pancreático/terapia , Neoplasias Pancreáticas/complicaciones , Neoplasias Pancreáticas/terapia , Esfinterotomía Endoscópica , StentsRESUMEN
The case of a 60-year-old female patient with watery diarrhea is reported. The history was characterized by prolonged diagnostic vagaries, due in part to histological features of ileal, rectal and duodenal biopsies which were suggestive of celiac disease. This was clinically excluded. After halting the intake of a compound drug containing saponins, administered for venous insufficiency, the diarrhea ceased immediately but could be provoked by rechallenge with the same drug. The patient thus had drug induced chronic diarrhea mimicking celiac disease, a condition which is less rare than is thought and easily diagnosed by a thorough enquiry on drug intake.
Asunto(s)
Enterocolitis/inducido químicamente , Saponinas/efectos adversos , Biopsia , Enfermedad Celíaca/diagnóstico , Colon/patología , Diagnóstico Diferencial , Enterocolitis/diagnóstico , Enterocolitis/patología , Femenino , Humanos , Íleon/patología , Mucosa Intestinal/patología , Persona de Mediana Edad , Saponinas/uso terapéutico , Insuficiencia Venosa/tratamiento farmacológicoRESUMEN
Sphincter of Oddi activity partly regulates bile flow into the small intestine. This regulation is mainly controlled by phasic contractions and basal tone of the sphincter, together with gallbladder contraction. Manometric studies of the sphincter have permitted a better understanding of its physiological role and implication in biliary dyskinesia symptoms. Motility abnormalities of Oddi's sphincter present classically as bouts of recurrent pain and/or idiopathic pancreatitis, that can be successfully cured by endoscopic sphincterotomy.
Asunto(s)
Discinesia Biliar/fisiopatología , Vaciamiento Vesicular , Esfínter de la Ampolla Hepatopancreática/fisiopatología , Discinesia Biliar/cirugía , Humanos , Manometría/métodos , Esfinterotomía EndoscópicaRESUMEN
Mortality in upper GI tract bleeding has not been affected by the introduction of diagnostic fibre optic endoscopy. Recently, however, several modes of treatment delivered through the endoscope have been shown to be effective in improving the outcome of bleeding ulcers. We have retrospectively evaluated the course of 58 patients who underwent endoscopic treatment of a bleeding ulcer. Hemostasis was initially obtained in 93% of patients. 19 (34%) had a relapse of hemorrhage and 15 of these underwent emergency operation. 5 patients (8.6%) died; one of these deaths was due to a complication of endoscopic treatment. Definitive hemostasis was obtained in 41 patients (71%). Endoscopic sclerotherapy of bleeding gastroduodenal ulcers is effective, simple, and cheap, and should be considered in all patients presenting a high risk of relapse.
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Úlcera Péptica Hemorrágica/terapia , Escleroterapia/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Endoscopía Gastrointestinal , Femenino , Técnicas Hemostáticas , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Terminal constipation is a common ailment which may be readily suspected by appropriate questioning of the patient. Investigation is by function tests such as anorectal manometry and measurement of colonic transit time. The goal of this investigation was to explore the relative merits of these two methods in terminal constipation. Measurement of colonic transit time did not make it possible to distinguish terminal from other forms of constipation, whereas anorectal manometry allowed this distinction and, in cases of terminal constipation, provided information on the physiopathological mechanisms, thereby permitting appropriate anorectal reeducation by biofeedback. We conclude that, once an organic cause has been excluded by coloscopy, anorectal manometry is the investigation of choice in terminal constipation.
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Canal Anal/fisiopatología , Colon/fisiopatología , Estreñimiento/fisiopatología , Tránsito Gastrointestinal , Adolescente , Adulto , Anciano , Biorretroalimentación Psicológica , Estreñimiento/rehabilitación , Femenino , Humanos , Masculino , Manometría , Persona de Mediana EdadRESUMEN
Over a 15-year period we have treated 50 patients with achalasia by pneumatic dilatation (61 dilatations). Perforation occurred in 5 patients, 2 of whom required surgery while the other 3 were successfully managed by conservative means. These 3 patients are reported on with reference to the indications and modalities of the medical treatment.
Asunto(s)
Acalasia del Esófago/terapia , Perforación del Esófago/terapia , Adulto , Analgésicos/administración & dosificación , Antibacterianos/administración & dosificación , Terapia Combinada , Dilatación/efectos adversos , Quimioterapia Combinada , Perforación del Esófago/etiología , Femenino , Antagonistas de los Receptores H2 de la Histamina/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Nutrición ParenteralRESUMEN
Constipation and fecal incontinence are frequent motives of gastroenterological consultation. An etiological diagnosis can often be suspected from the history and can be confirmed by functional testing. We here report our experience with the measurement of colonic transit time (TTC), anorectal manometry (MAR) and defecography (D). Whilst TTC was unhelpful, MAR revealed abdomino-pelvic asynchrony (anismus) in 60 constipated patients and 7 (47%) of 15 incontinent patients. Perineal descent was suspected in 25 constipated patients and confirmed by defecography, which also revealed associated static pelvic disorders. Our experience confirms the role of functional exploration in the investigation of constipation and fecal incontinence and permits a more precise therapeutic approach.
Asunto(s)
Estreñimiento/fisiopatología , Incontinencia Fecal/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Canal Anal/fisiopatología , Estreñimiento/diagnóstico , Defecación/fisiología , Incontinencia Fecal/diagnóstico , Femenino , Tránsito Gastrointestinal/fisiología , Humanos , Masculino , Manometría , Persona de Mediana Edad , Recto/fisiopatologíaRESUMEN
40 patients with achalasia underwent pneumatic dilatation. 25 were followed up for a mean duration of 3.96 years. Digestive symptoms disappeared in 32% of cases, were diminished in 40% and remained unchanged in 28%. In 8 patients oesophageal manometry after dilatation showed a significant reduction in lower oesophageal sphincter pressure. The patients showing improvement had a more marked drop in lower oesophageal sphincter pressure, lower residual pressure in the lower oesophageal sphincter measured by wet swallows, and negative pressure in the oesophagus. As complications 3 patients developed oesophageal perforation with one subsequent death, and 3 symptomatic gastro-oesophageal reflux. In view of these results, we regard pneumatic dilatation as the treatment of choice in achalasia.
Asunto(s)
Cateterismo/métodos , Acalasia del Esófago/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Cateterismo/efectos adversos , Acalasia del Esófago/fisiopatología , Perforación del Esófago/etiología , Unión Esofagogástrica/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Manometría , Persona de Mediana Edad , PresiónRESUMEN
Biliary complications have recently been reported in patients with AIDS. This may take the form of acalculous cholecystitis or more commonly cholangitis, which may or may not be associated with stenosis of the papilla. These conditions must be sought in patients presenting with right hypochondrial pain and elevated alkaline phosphatase. Infection with Cryptosporidium or cytomegalovirus is often associated.
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Síndrome de Inmunodeficiencia Adquirida/complicaciones , Conductos Biliares Intrahepáticos , Colangitis/complicaciones , Adulto , Fosfatasa Alcalina/sangre , Colangiografía , Colangitis/sangre , Colangitis/diagnóstico , Humanos , Masculino , UltrasonografíaRESUMEN
Of 69 patients with non-cardiac chest pain, one third had abnormal esophageal motility as evidenced by basal esophageal manometry. 8 patients (12%) reported chest pain during a provocation test (edrophonium). While this pain seemed similar to the spontaneous chest pain described by 7 patients, it was not associated with manometric changes in 30% of these cases. The causal relationship between disorders of esophageal motility and non-cardiac chest pain has still to be confirmed, and caution must be exercised in interpreting edrophonium tests.
Asunto(s)
Dolor en el Pecho/diagnóstico , Edrofonio , Trastornos de la Motilidad Esofágica/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Dolor en el Pecho/etiología , Trastornos de la Motilidad Esofágica/complicaciones , Reacciones Falso Positivas , Femenino , Motilidad Gastrointestinal/efectos de los fármacos , Humanos , Masculino , Manometría/métodos , Persona de Mediana EdadRESUMEN
60 consecutive patients underwent sclerotherapy for hemorrhage from ruptured esophageal varices. Sclerosis was always started within the first 48 hours. 12 patients (20%) died during initial hospitalization, but only 5 from recurrent bleeding. Of 48 survivors, 22 (46%) did not rebleed during a mean 18-month follow-up, whereas 26 (54%) had recurrences, 27 of these bleeding episodes occurred early (within 4 months) and 17 late (mean 16.5 months). Eradication of the varices was achieved in 29 patients (60%) with a mean of 6.2 sessions and within a mean of 6 months. Of these 48 patients 2 have been lost to follow-up, 25 (52%) are alive after a mean follow-up of 29 months, and 21 (44%) died (though only 2 from variceal bleeding). The survival curve (Kaplan-Meier) of these 60 bleeders is 45% and 37% at 2 and 4 years respectively. Sclerotherapy caused no death and only minor adverse effects. These results confirm those in the literature. We advocate endoscopic sclerosis as first choice in the treatment of ruptured esophageal varices.