Common bile duct stones in acute biliary pancreatitis: an endoscopic study.

The knowledge of the natural history of common bile duct stones in biliary pancreatitis may be helpful in the debate concerning the timing of endoscopic sphincterotomy in relation to surgery. The endoscopic cholangiographies of 211 patients with biliary pancreatitis were analyzed. The presence of bile duct stones was recorded, as well as the time interval between admission and endoscopic retrograde cholangiopancreatography (ERCP). The predicted severity of pancreatitis was determined by the modified Glasgow criteria. The overall incidence of bile duct stones was 28.9%. This incidence was 43.8% during the first 2 days and decreased to < 20% after 1 week. There was no correlation between the severity of disease and the presence of bile duct stones. The performance of an ERCP 1 week after the admission for biliary pancreatitis will avoid a substantial number of unnecessary endoscopic sphincterotomies. Prediction of the severity of disease does not alter the yield of bile duct stones.

Proton-pump inhibition and gastric giardiasis: a causal or casual association?

Two patients who developed gastric giardiasis after 2 weeks of treatment with omeprazole 20 mg b.i.d. followed by omeprazole 20 mg per day for 2-6 weeks are described. In one patient, gastric giardiasis occurred in the presence of only mild intestinal metaplasia. In the other patient, Giardia lamblia infection had resolved 4 weeks after the cessation of omeprazole treatment, which, to our knowledge, is the first case reported in the literature. It is tempting to speculate that gastric giardiasis can develop in the absence of mucosal abnormalities during hypochlorhydria induced by treatment with a high dose of a proton-pump inhibitor. Specific treatment may not be required if the drug can be stopped and no other gastric disease causing hypochlorhydria is present.

Endoscopic ultrasonography and esophageal cancer.

Endoscopic ultrasonography (EUS), performed by means of an endoscope equipped with an ultrasound transducer, has been used in the imaging, staging, and follow-up of esophageal cancer for a decade. Although at first considered as a more or less experimental procedure, it emerged in the last six years as a valuable and precise tool for the assessment of various upper GI disorders. It is now well established that EUS can provide more accurate staging information on upper GI pathology than other imaging techniques such as conventional radiology, conventional ultrasound, CT, MRI and endoscopy. However, it remains complementary to other imaging methods, and is not suited for routine screening purposes. The instrumentation, technique, limitations, pitfalls, accuracy, and possible future of EUS are discussed, particularly concerning esophageal cancer.

Peroperative ultrasonography in the diagnosis of splenic vein thrombosis.

A case of recurrent bleeding from gastric varices due to isolated splenic vein thrombosis is reported. There was no evidence of pancreatic, retroperitoneal or infectious disease. The final diagnosis was made by intraoperative ultrasonography during an emergency laparotomy for massive bleeding from a ruptured gastric vein. Splenectomy is the treatment of choice in this case. The patient was cured after splenectomy.

Pneumomediastinum after self-dilation of the esophagus.

Pneumomediastinum following esophageal perforation is a known complication of Eder Puestow dilation for esophageal stenosis. This is the first reported case of esophageal perforation and pneumomediastinum occurring after instrumental self-dilation of a stenotic esophageal lesion. The observed 0.02 percent perforation rate in this patient (compared to the reported 0.3 percent in Eder Puestow "hetero"-dilation) makes the Eder Puestow auto-dilation procedure seem justifiable in a well-trained and well-informed patient.

Infusion of propofol ('Diprivan') as sedative technique for colonoscopies.

Sixty male and female patients, scheduled for colonoscopy were premedicated with glycopyrrolate 0.4 mg intramuscularly. Anaesthesia was induced with 2 mg/kg propofol ('Diprivan') and maintained with a continuous infusion of propofol at a rate of 3, 6 or 9 mg/kg/h randomly allocated. Patients lost consciousness within 60.6 +/- 18.7 (s.d.) s. Preservation of the hypnotic effect was infusion-rate dependent as 15, 40 and 85% of the patients were unconscious on infusion rates of 3, 6 or 9 mg/kg/h propofol, respectively. A high degree of sedation was observed in the remaining patients with an incidence of 40, 35 and 0% in the different series. Sedation was light in the remainder of the patients. To increase the acceptability of the procedure, a supplemental bolus of propofol and/or an increase in the infusion rate were required in 40, 15 and 10% of the 3, 6 and 9 mg/kg/h infusion rate groups, respectively. The incidence of amnesia was similar in all three groups (80, 90 and 95%, respectively). Recovery was significantly longer with increasing infusion rate, but remained rapid. The longest time was 7.3 +/- 4.0 min to open eyes on command and 10.6 +/- 4.6 min to answer correctly. The most important side effects were pain on injection (50%) and some restlessness during maintenance (25%). Blood pressure decreased, but heart rate was unaffected. Patients breathed room-air spontaneously. Respiratory rate slowed after induction then increased rapidly above baseline values. The incidence of apnoea was 48% with a mean duration of 51 +/- 22s (s.d.). The technique was evaluated as good or adequate in 95% of the cases. We suggest than an analgesic premedication followed by an average of 6 mg/kg/h propofol by infusion might be a simple and convenient method of achieving good conditions for colonoscopy.

Carcinoma of cystic duct leading to obstructive jaundice.

Twenty-one cases of primary carcinoma of the cystic duct have been reported in the literature. Most cases were characterized by a hydrops or cholecystitis, whereas only two patients presented with jaundice. To our knowledge, this is only the third case of obstructive jaundice caused by a primary cystic duct carcinoma. The patient was treated by cholecystectomy with resection of the cystic duct tumor and a portion of the common bile duct. Reconstruction was performed by a Roux-en-Y choledocojejunostomy.

Measurement of thyroxine conversion to triiodothyronine using human lymphocytes. A useful and simple laboratory technique.

The deiodination of T4 to T3 has been studied after incubation of whole lymphocytes with different T4 concentrations, followed by a T3 radioimmunological determination performed on unextracted samples. The lymphocytes were isolated from blood from normal volunteers of both sexes and different age classes as well as from myxedematous subjects and patients with low T3 syndrome. The T3 production, in normal subjects, expressed as pmol/10.10(6) cells was 0.41 +/- 0.75 (T4 = 4.10(-7) M, n = 12), 1.43 +/- 0.14 (T4 = 4.10(-6) M, n = 26) and 1.65 +/- 0.29 (T4 = 8.10(-6) M, n = 11). There was no sex or age-related difference. In 3 myxedematous patients the T3 production was lower than the corresponding value obtained in normal subjects. The T3 production in patients with low T3 syndrome was lower than in controls (p less than 0.001); an inverse correlation was found between the T3 production and the serum rT3 levels, whereas no correlation could be found with serum T3 levels.

[Amiodarone-induce "low T3-syndrome" (author's transl)]. / "Low T-syndrome" provoqué par l'amiodarone.

Amiodarone induces in patients "low T3-syndrome" characterized by normal T4. T3 resin uptake and free T3, contrasting with low T3 and free T4 values, and enhanced concentration of r-T3.

[Digestive origin of Campylobacter septicemias]. / L'origine digestive des septicémies à Campylobacter

Whilst the animal origin fo human Campylobacteriosis is generally accepted, its epidemiology remains ill understood. Animal contact prior to a Campylobacter septicaemia is only rarely found. The frequent occurrence of episodes of diarrhoea immediately prior to the onset has led to a suspicion of a digestive portal of entry. Our aim is to provide incontrovertible proof of this hypothesis, reporting the results of systematic stool examinations for Campylobacter in the stools as well as 5 new cases of septicaemia.

Treatment of diabetic coma with small intravenous insulin boluses.

The clinical efficacy of small intravenous boluses of insulin in treating diabetic decompensation was tested in 23 patients presenting in either a ketoacidotic or a nonketotic diabetic coma. In addition to the usual ionic and fluid replacement, the patients received hourly intravenous injections of insulin 5 IU. This dose lowered blood glucose levels in all but two patients. In the patients who responded the percentage decrease in glycaemia was similar whatever the initial glucose concentration and averaged (+/-SE of mean) 50+/-3% in five hours. Close monitoring of insulin and glucose concentrations after intravenous insulin in three patients showed that despite the short half life of insulin the effect of the intravenous bolus lasted for about 60 minutes. The overall clinical effectiveness of this type of treatment is comparable to that of the other low-dose regimens. Owing to its simplicity, this technique of insulin administration seems most suitable for the routine treatment of diabetic coma.