Toothpick inside the Common Bile Duct: A Case Report and Literature Review.

The incidence and prevalence of foreign body (FB) ingestion are difficult to estimate. Unlike other foreign bodies, the ingestion of a toothpick is very uncommon and carries high morbidity and mortality rates. We report a case of a 73-year-old female patient presenting mid-term epigastric pain. Abdominal ultrasound revealed a slightly dilated common bile duct (CBD) and magnetic resonance showed an irregular filling failure in distal CBD and gallstones. Endoscopic Retrograde Cholangiopancreatography revealed major papilla on the edge of a diverticulum and confirmed the distal filling failure. After sphincterotomy, a partially intact toothpick was extracted from the CBD. Neither fistulas nor perforation signs were found. Literature related to foreign bodies and toothpick ingestion was reviewed and some hypotheses to explain the reported case were created. To our knowledge, this is the first report of a toothpick lodged inside the biliary tract.

Quimio-radioterapia em carcinoma tipo "oat cell" do esôfago / Chemoradiotherapy in oat cell carcinoma of esophagus

É relatado um caso de um paciente com carcinoma indiferenciado de pequenas células originário no esôfago que foi tratado com quimio-radioterapia. Durante a quimioterapia de induçäo com Ciclofosfamida, Epirrubicina e Etoposide houve desaparecimento completo da neoplasia. A radioterapia foi utilizada para consolidaçäo da resposta. Dois anos e meio após diagnóstico o paciente foi a óbito após desenvolvimento de múltiplas metástases.

Immediate effects of the endoscopic sphincterotomy on the motility of the sphincter of Oddi.

An endoscopic manometric technique was used to determine the CBD-duodenum junction pressure profile before and immediately after endoscopic sphincterotomy in 13 patients with common bile duct stones. Premedication (meperidine, atropine, and diazepam) was given to all patients and endoscopic retrograde cholangiopancreatography was performed before endoscopic sphincterotomy. In the patients with intact papilla the features of the sphincter of Oddi motility were similar to those previously described for patients not given premedication or submitted to cholangiography before endoscopic sphincterotomy. Endoscopic sphincterotomy which was successful for immediate stone removal in 9 of 13 patients caused an immediate reduction of sphincter of Oddi motility in all patients, but abolished it in only 2 of them. The present results show that successful common bile duct stone extraction by means of endoscopic sphincterotomy can be accomplished without total abolition of sphincter of Oddi motility.

Evaluation of vagotomy by the Hollander-Congo red test.

In the present study, the completeness of vagotomy in patients who underwent truncal and highly selective vagotomy is evaluated, comparing them with control groups of normal persons and patients with a duodenal ulcer. The evaluation was made by the Hollander test, followed by the endoscopic Congo red test, using the same hypoglycemic stimulus. Gastric acid production was higher in the patients with duodenal ulcer, followed by the normal persons. Lower acidity levels were obtained for patients with truncal vagotomy than for patients with highly selective vagotomy. During the Congo red test, we noted that the patients with truncal or highly selective vagotomy had small black spots in the gastric mucosa, except those having a recurrent ulcer, denoting incomplete vagotomy. Nevertheless, when we observed the appearance of the gastric mucosa, we noted a similar aspect for those having had a vagotomy and for normal persons. This appearance was completely different from the patients with a duodenal ulcer. We concluded that truncal vagotomy greatly reduces the level of gastric acid production, while highly selective vagotomy does so to a lesser extent. The endoscopic aspect of these patients during the Congo red test was similar to that for normal persons.

Teste do vermelho congo com estimulo pela insulina para avaliacao da integralidade vagal apos vagotomia. / Congo red test with insulin stimulation for evaluation of vagal integrity after vagotomy

Os autores propoem um metodo para a avaliacao da integralidade vagal apos vagotomia, baseado nas propriedades tintoriais do indicador de pH vermelho congo. O metodo consiste na realizacao do teste de Hollander com injecao intravenosa de 0,2-0,3U de insulina por kg de peso (nao ultrapassando 20U). Imediatamente apos completar o teste de Hollander (120 min apos a injecao da insulina), com a glicemia em niveis iguais ou inferiores a 50 mg%, a mucosa gastrica e endoscopicamente tinta com vermelho congo. Nas areas com pH abaixo de 3,4 (niveis estabelecidos para viragem do vermelho congo a 1% de diluicao), a mucosa aparece corada em negro, denotando acao mediada pelo vago em funcao do estimulo hipoglicemico induzido pela insulina, por tanto, fibras vagais gastricas intactas.Esse teste foi empregado em l0 pacientes submetidos a vagotomia troncular e operacao de drenagem, por ulcera duodenal, ha mais de 5 anos. Observamos em 6 pacientes areas tintas em negro, denotando vagotomia incompleta. Comparando com outros metodos para avaliacao da vagotomia, o teste do vermelho congo com estimulo hipoglicemico induzido pela insulina mostrou-se mais sensivel