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Biomedical subjects

D L Carr-Locke

Publications and source records attributed to D L Carr-Locke.

At least 109 records · Page 6Linked to original sources
PubMed1987

Hemobilia treated by nasobiliary catheterization.

Hemobilia results in obstructive jaundice because blood clots may obstruct the bile duct. Decompression relieves jaundice, promotes clot lysis, and may encourage cessation of bleeding. We report a case of hemobilia that followed needle biopsy of the liver and was managed nonoperatively with an endoscopically placed nasobiliary catheter.

Adult↗
PubMed1987

Bile peritonitis and hemobilia after percutaneous liver biopsy: endoscopic retrograde cholangiopancreatography demonstration of bile leak.

A 29-yr-old woman developed portal hypertension secondary to congenital intrahepatic multiple microhamartomata. Percutaneous liver biopsy was complicated by both bile peritonitis and hemobilia. Endoscopic retrograde cholangiopancreatography was used to demonstrate the bile leak. Abdominal paracentesis failed to control the leak, which was managed by surgery. Endoscopic drainage by nasobiliary intubation with suction might have avoided surgery.

Adult↗
PubMed1986

A prospective study of ERCP and endoscopic sphincterotomy in the diagnosis and treatment of gallstone acute pancreatitis. A rational and safe approach to management.

From a consecutive series of 112 patients with acute pancreatitis, 70 patients with suspected gallstones were randomized to urgent endoscopic retrograde cholangiopancreatography (ERCP) (less than 72 hours) and endoscopic sphincterotomy (ES) if choledochal stones were present (n = 35), or to conventional treatment (n = 35). Endoscopic retrograde cholangiopancreatography, successful in 89% of cases, indicated choledochal stones in 11 patients, all of whom underwent successful stone retrieval by ES. Later during hospital admission, ERCP was performed in 13 more patients and choledochal calculi were extracted from two patients by ES. No complications were attributable to ERCP or ES. Two patients died of biliary pancreatitis; both had been conventionally treated and may have benefited from urgent ERCP/ES. Our experience, which extends to another 24 patients with ERCP and ten with ES during acute pancreatitis, indicates that these are safe techniques and deserve wider consideration in the management of acute pancreatitis.

Acute Disease↗
PubMed1986

Endoscopic sphincterotomy for retained common bile duct stones in patients with T-tube in situ in the early postoperative period.

We report on thirty-nine patients who underwent endoscopic sphincterotomy (ES) and stone extraction for retained common bile duct calculi with a T-tube in situ. Sixteen of the patients had undergone unsuccessful attempts at removal by flushing or dissolution by cholesterol solvents. A total of 76 stones were present: 53 distal to the T-tube and 23 proximal to the T-tube. ES and clearance of the common bile duct was achieved in 37 patients (95 per cent) and complications occurred in three patients (7.7 per cent). This method is an effective and relatively safe method in the early postoperative period allowing rapid treatment during the same admission as for the original operation and early hospital discharge.

Adult↗
PubMed1986

Management of acute cholangitis and the impact of endoscopic sphincterotomy.

Ninety-four patients admitted to Leicester Hospitals with acute cholangitis since 1977 were reviewed to coincide with the availability of endoscopic sphincterotomy (ES). Thirty-four were men and sixty were women, their mean age was 69.7 years and the median hospital stay was 20 days. There were 15 deaths (16 per cent) by 30 days in patients with significantly lower initial serum albumin levels (P less than 0.005) and significantly higher serum urea levels (P less than 0.05) than survivors. Eighty-two patients had common bile duct (CBD) calculi of whom 71 underwent early decompression of the biliary tree either surgically (28) or by ES(43). Early surgical decompression was associated with a significantly higher 30 day mortality (6/28) than early ES (2/43) (P less than 0.02) despite the fact that patients undergoing early ES were significantly older (P less than 0.02) and had significantly more medical risk factors (P less than 0.05). Of the 43 patients undergoing early ES 7 had had a previous cholecystectomy, 13 underwent subsequent elective cholecystectomy with no mortality and the remaining 23 had the gallbladder left in situ because of advanced age (mean age 79 years) and frailty. Only 2 of the 23 have since required cholecystectomy. We suggest that patients with acute cholangitis who do not rapidly respond to conservative treatment should undergo early ES with early surgery reserved for those who do not improve following ES. Elective cholecystectomy following successful ES can often be avoided in the elderly and frail.

Acute Disease↗
PubMed1986

Tumours and pseudotumours of the region of the ampulla of Vater: an endoscopic, clinical and pathological study.

From a large series of patients referred for endoscopic retrograde cholangiopancreatography to one endoscopist, 49 patients had the duodenoscopic appearance of a periampullary tumour. Thirty eight of these lesions were neoplastic, but the remaining 11 patients had inflammatory non-neoplastic lesions (pseudotumours). These could not be distinguished from the neoplasms on endoscopic appearances. The cholangiopancreatograms were similar except that the diameter of the pancreatic duct tended to be higher in the tumour group and gall stones were present significantly more often in the patients with pseudotumour. Endoscopic biopsy correctly diagnosed 28 of 34 ampullary carcinomas. Two of the 11 pseudotumour patients were subjected to surgical excision biopsy because of suspicious histological features of endoscopic biopsy. In the neoplastic group 19 patients underwent Whipple's procedure, seven surgical bypass, seven endoscopic sphincterotomy only and five died without successful biliary drainage. The overall one year survival was 44.7%. By contrast, the patients with pseudotumours were clinically well at a median follow up 24 months (range 12-41 months), after endoscopic sphincterotomy except for one 89 year old patient who died 22 months later from unrelated causes.

Adult↗
PubMed1986

The role of clinical and biochemical criteria and endoscopic retrograde cholangiopancreatography in the urgent diagnosis of common bile duct stones in acute pancreatitis.

The role of clinical and biochemical criteria in predicting common bile duct (CBD) stones was analyzed in 76 patients with acute pancreatitis undergoing endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Forty patients had ERCP within 72 hours; cholangiography was successful in 92%. Fifty patients had biliary pancreatitis; 25 patients had CBD stones and all were successfully removed by endoscopic sphincterotomy (ES). Twenty-six patients had nonbiliary pancreatitis. Two patients had complications from ERCP and/or ES; two patients died (no CBD stones) but ERCP was noncontributory. Significant differences were found between the biliary and nonbiliary disease groups with respect to age, and bilirubin. gamma-glutamyl transpeptidase, alkaline phosphatase, alanine transaminase, and amylase levels. The first four factors also discriminated between those patients with and without CBD stones. Logistic discriminant functions were estimated providing probabilities for the presence of CBD stones for each patient but were too cumbersome for clinical use. A simple scoring system was devised on the basis of cut-off levels: bilirubin greater than or equal to 40 mumol/L, gamma-glutamyl transpeptidase greater than or equal to 250 IU/L, alkaline phosphatase greater than or equal to 225 IU/L, and age greater than or equal to 70 years, indicating CBD stones. Bilirubin alone had a sensitivity and specificity of 80%; the specificity increased to 93% with all four factors. These results suggest that clinical and biochemical criteria and ERCP and/or ES may have important roles in the management of patients with suspected biliary pancreatitis.

Acute Disease↗
PubMed1985

Successes, failures, early complications and their management following endoscopic sphincterotomy: results in 394 consecutive patients from a single centre.

The indications and results of 394 endoscopic sphincterotomies (ES) performed over a 6 year period from a single centre are described. The indications for ES were common bile duct (CBD) calculi (81 per cent), papillary stenosis (9 per cent), periampullary tumours, insertion of endoprostheses, sump syndrome and biliary dilatation for benign strictures. ES was achieved in 98 per cent of patients. In the calculus group the CBD was cleared of stones in 93.3 per cent following a successful ES (92 per cent overall success rate for CBD clearance). Early complications (less than or equal to 1 month) occurred in 41 patients (10.4 per cent) of which haemorrhage accounted for nearly half. Emergency surgery following ES was undertaken in 15 patients (3.8 per cent). There were 13 deaths within one month of ES (3.3 per cent) of which three were directly attributable to ES (0.8 per cent). The diagnosis and management of complications following ES is important with increasing numbers of patients being treated from outside the referral centre.

Acute Disease↗
PubMed1985

Sump syndrome following choledochoduodenostomy and its endoscopic treatment.

The clinical features of eight patients with 'sump syndrome' following side-to-side choledochoduodenostomy are reported. The syndrome is defined and its aetiology discussed with special reference to debris in the common bile duct, bacterial overgrowth and the clinical picture of acute cholangitis, which does not appear to be necessary for the diagnosis to be made. Five patients were successfully treated by endoscopic sphincterotomy and a sixth by endoscopic removal of food debris from the sump. The other two patients had further surgery.

Aged↗
PubMed1985

Effects of exogenous secretin on pancreatic and biliary ductal and sphincteric pressures in man demonstrated by endoscopic manometry and correlation with plasma secretin levels.

An endoscopic manometric technique was used to investigate the effects of exogenous secretin on pancreatic duct, common bile duct, pancreatic duct sphincter, and bile duct sphincter pressures in 20 healthy volunteers. Synthetic secretin was infused intravenously at rates of 8.05, 16.1, 32.2, 64.4, 129, 258, and 516 ng/kg/hr, and plasma secretin concentrations were measured by a radioimmunoassay. Secretin produced a significant fall in peak and trough pancreatic duct sphincter pressures from basal values of 48.2 +/- 7.9 mm Hg (mean +/- SD) and 16.9 +/- 7.7 mm Hg, respectively, to 34.4 +/- 6.8 mm Hg and 11.2 +/- 5.8 mm Hg (P less 0.005), respectively, at a mean plasma secretin concentration of 16 pg/ml (during an infusion rate of 32.2 ng/kg/hr). Higher infusion rates had no additional effect. Pancreatic duct pressure became significantly elevated above basal (11.5 +/- 4.0 mm Hg) at the two highest secretin rates. Secretin had no effect on common bile duct or bile duct sphincter pressures. Plasma secretin concentrations were within the postprandial range during the lowest four secretin infusion rates. We conclude that secretin produces selective physiological relaxation of the pancreatic duct sphincter.

Adult↗
PubMed1985

Effects of sphincteroplasty and endoscopic sphincterotomy on the bacteriologic characteristics of the common bile duct.

Forty-five patients with sphincter of Oddi stenosis had specimens of common bile duct cultured during ERCP before either sphincteroplasty or endoscopic sphincterotomy. All had sterile bile before sphincter ablation. Bile was recultured 6 to 36 months later during endoscopy at which time 70 percent of the sphincterotomy and 76 percent of the sphincteroplasty patients had bile colonized principally by enteric organisms. Growth was heavy to moderate in most of the patients and contained few nasopharyngeal organisms. Despite bactobilia, no patient had symptomatic cholangitis, presumably due to excellent drainage of bile. The most likely source of the bactobilia is from direct extension of duodenal organisms into the common bile duct.

Adult↗
PubMed1985

Detection of gall stones after acute pancreatitis.

Four methods of gall stone diagnosis after an attack of acute pancreatitis are analysed. Of 128 consecutive patients with acute pancreatitis, 99 patients were discharged from hospital without a definite aetiology. These patients had biochemical tests performed on admission and ultrasonography and oral cholecystography performed six weeks later. The sensitivity for ultrasonography was 87% and the specificity was 93%; the respective figures for oral cholecystography were 83% and 90%. The predictive value of positive ultrasonography was 100% and of negative ultrasonography 75%; the respective values for oral cholecystography were 95% and 68%. A combination of ultrasonography and oral cholecystography failed to detect nine of 70 patients with gall stones (13%). Of 35 patients with normal ultrasonography and oral cholecystography, 33 patients had an endoscopic retrograde cholangiogram (ERCP) which showed gall stones in a further seven patients. All three methods failed to reveal gall stones in two patients, confirmed by laparotomy. The sensitivity of admission biochemical analysis was 73% and the specificity was 94%; the predictive value of a positive result was 97% and of a negative result was 57%. Biochemical analysis predicted gall stones in six of the seven patients shown by ERCP. Only 9% of patients were finally considered to be idiopathic. In conclusion ultrasonography is the investigation of choice and ERCP should be undertaken in all patients who have normal ultrasonography and/or oral cholecystography but have biochemical criteria indicative of gall stones.

Acute Disease↗
PubMed1984

The management of common bile duct calculi by endoscopic sphincterotomy in patients with gallbladders in situ.

Endoscopic sphincterotomy (ES) is widely used in the treatment of patients with common bile duct (CBD) stones following cholecystectomy. The technique has now been extended to patients with gallbladders still present and the results of ES in 100 such patients is reported. Fifty-nine were considered unsuitable for surgery (Group A), in 38 ES was performed as a preliminary to cholecystectomy (Group B) and in 3 ES was performed following emergency cholecystostomy (Group C). ES was achieved in 98 patients and stones completely extracted in 91 patients. In Group A 5 patients required surgery, in 3 because of technical failure and in 2 because of empyema of the gallbladder. One patient who presented in extremis died following failure to extract a large CBD stone. On follow-up (4-50 months), 16 patients have died but in only one from gallbladder sepsis, and one has had a cholecystectomy for pain. In Group B choledochotomy was avoided in 29 of the 37 patients who agreed to cholecystectomy. In Group C no further surgery was required and all patients in Groups B and C remain well. These results indicate that ES is an effective technique for treating patients with CBD stones with the gallbladder in situ, either alone in patients considered unsuitable for surgery or as an adjunct to surgery.

Aged↗
PubMed1984

The urgent diagnosis of gallstones in acute pancreatitis: a prospective study of three methods.

Ultrasonography (US), radionuclide biliary scanning (RBS), and biochemical tests were performed within 72 h of admission in 83 patients with acute pancreatitis in an attempt to define those with gallstones as an aetiological factor. US was 92 per cent accurate in the 80 per cent of patients in whom the gallbladder was demonstrated. There were no false positives. Sixty-seven per cent of patients with gallstones were diagnosed although this improved to 78 per cent when US was repeated following the patients' clinical improvement. The pattern of RBS was completely normal in 46.5 per cent of patients with biliary pancreatitis and 64 per cent of patients with non-biliary pancreatitis. Biochemical tests completely separated 47 per cent of patients with gallstones from those without. Used in combination with US these two methods accurately identified 81 per cent of patients in the biliary group. In conclusion US was found to be a rapid and accurate method of gallstone detection but used alone it has limited usefulness. RBS can be time consuming and was found to be of doubtful value. Biochemical tests were helpful in indicating a proportion of patients who had gallstones which were not detected by US, and therefore have a practical application. Current methods of gallstone detection in patients with acute pancreatitis are far from ideal and further studies are indicated.

Acute Disease↗