[Ultrasound-guided extracorporeal piezoelectric lithotripsy of bile duct calculi]. / Ultraschallgesteuerte extrakorporale piezoelektrische Lithotripsie (EPL) von Gallenwegskonkrementen.

AIM: Extracorporeal shock-wave lithotripsy (ESWL) with underwater spark discharge and stone localisation via x-ray has become established in the treatment of difficult bile duct stones. First results with the piezoelectric lithotripter (EPL) in our department have also been promising. METHOD: Between 1989 and 1993 we were able to treat 79 patients (mean age 76 years) with problematic bile duct stones with the EPL. Twenty-seven patients had solitary stones, 52 patients presented with multiple stones. Seventy-one patients received a nasobiliary tube to decompress the biliary system. For extracorporeal lithotripsy, we used a piezoelectric lithotripter (Piezolith 2300, R. Wolf, Knittlingen, Germany). RESULTS: Visualisation of the stones by ultrasound and ensuing treatment were possible in 71 out of 79 patients (90%), and complete stone removal was achieved in 62 patients (78.5%) after 7,595 shock-waves were applied per patient on average. In 55 patients, endoscopic extraction of fragments was performed to avoid fragment complications. Nearly all patients in whom extracorporeal lithotripsy failed were cleared of their stones by additional use of intracorporeal electrohydraulic lithotripsy. Three patients received palliatively an endoprosthesis and two patients were referred to surgery. CONCLUSION: EPL with sonographic stone localisation and mild sedo-analgesia is a valuable adjunct in the treatment of difficult biliary tract calculi. It is a worthwhile alternative especially for elderly patients who would be at high risk on general anaesthesia.

[Erythrohepatic protoporphyria. A rare differential diagnosis of parenchymatous jaundice]. / Erythrohepatische Protoporphyrie. Eine seltene Differentialdiagnose des parenchymatösen Ikterus.

Parenchymatous jaundice persisted in a 59-year-old woman[correction of man] after cholecystectomy for gallbladder stones. She had a history of skin sensitivity to light. Laboratory tests demonstrated an excessive increase of free protoporphyrin in red blood cells and plasma, as well as abnormal coproporphyrinuria, indicating the diagnosis of far advanced erythropoietic protoporphyria with an hepatobiliary component. Conservative treatment with ursodeoxycholic acid brought no relief and liver transplantation was therefore performed. Bilirubin concentration and all other liver parameters became normal within 2 months postoperatively. No complications have occurred in a follow-up period of one year. The combination of light-sensitive skin with gall-stones and, at a later stage, parenchymatous jaundice should always make one consider protoporphyria. As recognition of the initial liver phase in erythropoietic protoporphyria is decisive for the success of treatment, regular examination of liver parameters and of the porphyrins in blood, urine and stool is recommended.