PubMed Health⌕ Search

Biomedical subjects

J Devière

Publications and source records attributed to J Devière.

At least 127 records · Page 7Linked to original sources
PubMed1995

Cholangiographic findings in deteriorating primary sclerosing cholangitis.

BACKGROUND AND STUDY AIMS: The evolution of primary sclerosing cholangitis (PSC) is difficult to predict, and ERCP may be helpful in diagnosing its complications and treating them. Few descriptions of cholangiographic findings during the course of the disease have yet appeared. We report here on our experience in the management and follow-up by ERCP of six patients with deteriorating PSC. PATIENTS AND METHODS: Between 1981 and 1992, PSC was diagnosed in 18 patients. Clinical, biochemical, and cholangiographic findings were recorded during the follow-up period. An initial group of 12 patients had a good clinical and biochemical course (mean 56 months) and did not require systematic control ERCPs. A second group of six patients, showing cholangiographic features similar to those of the first group at presentation, developed clinical and biochemical deterioration within a mean period of 43 months (range 6-96). RESULTS: These six patients had a significant elevation of serum bilirubin and at ERCP showed worsening bile duct lesions, with marked strictures and a subsequent increase in the maximum duct diameter in both the extrahepatic and intrahepatic ducts compared to the initial ERCPs. In two of these six patients, the strictures were due to a superimposed cholangiocarcinoma. Endoscopic drainage was unsuccessful, transplantation impracticable due to extrahepatic spread, and both patients died three and five months, respectively, after diagnosis of cholangiocarcinoma. By contrast, four patients with dominant extrahepatic duct involvement benefited from endoscopic procedures (mean follow-up 19 months) without any recurrence of cholangitis and without requiring long-term antimicrobial treatment. The follow-up checks included regular ERCPs performed every six months for duct and stent assessment, and cytology brushing. CONCLUSIONS: Since there are no effective means of early and accurate detection of cholangiocarcinoma, the use of ERCP to compare the course of cholangiographic lesions over time may be of interest. Patients with extrahepatic duct involvement may benefit from endoscopic therapy. By contrast, in patients with dominant intrahepatic duct disease and a deteriorating clinical status, attempts at endoscopic therapy are not helpful, and liver transplantation needs to be considered promptly.

Adult↗
PubMed1995

Antibiotic prophylaxis for infectious complications after therapeutic endoscopic retrograde cholangiopancreatography: a randomized, double-blind, placebo-controlled study.

We performed a randomized, double-blind, placebo-controlled trial of antibiotic prophylaxis before diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in 82 uninfected patients with cholestasis due to biliary tree obstruction of single or multiple causes. The patients were assigned to receive piperacillin (4 g) or placebo three times daily; prophylaxis was started just before initial ERCP and was continued until biliary drainage was completely unobstructed (by one or more ERCP procedures); the maximal duration of prophylaxis was 7 days. Nine patients were withdrawn from the study, and five others could not be assessed because of protocol violations. The 68 clinically evaluable patients underwent 81 therapeutic ERCP procedures. Clinical success (defined as an absence of fever, cholangitis, and clinical signs of sepsis during the 48 hours after the last dose of piperacillin or placebo) was documented for 32 (94%) of the 34 patients given piperacillin and for 24 (71%) of the 34 patients given placebo (odds ratio, 6.66; P = .01). Complete biliary drainage influenced clinical outcome favorably (odds ratio, 5.0; P = .02). All seven instances of bacteriologic failure (bacteremia) involved patients in the placebo group (P < .01). We concluded that antimicrobial prophylaxis significantly reduces the incidence of septic complications after therapeutic ERCP among patients presenting with cholestasis.

Adult↗
PubMed1995

Primary achalasia: analysis of endoscopic ultrasonography features with different instruments.

The examination of patients with primary achlasia using classical radial endoscopic ultrasonography lacks accuracy and has yielded inconclusive results. The diameter of the scope and the presence of a balloon makes examination of a short stenotic segment difficult. These techniques, however, are useful in the evaluation of patients with suspected pseudoachalasia due to tumor infiltration.

Endoscopy, Digestive System↗
PubMed1995

Role of defective monocyte interleukin-10 release in tumor necrosis factor-alpha overproduction in alcoholics cirrhosis.

Monocytes of patients with alcoholic cirrhosis produce higher amounts of tumor necrosis factor-alpha (TNF-alpha) after lipopolysaccharide (LPS) stimulation. The mechanisms of the overproduction remain undefined. IL-10 (IL-10) is an antiinflammatory cytokine known to downregulate TNF-alpha secretion by monocytes. The present study analyzes IL-10 production by monocytes and its control on TNF-alpha secretion in alcoholic cirrhosis. LPS-stimulated monocytes from alcoholic cirrhotics (n = 13) showed decreased IL-10 (median, 240 pg/mL [40 to 500] upsilon 513 pg/mL [152 to 1,335]; P = .01) compared with controls (n = 13). Cells from cirrhotic patients were normally responsive to recombinant IL-10, which induced a dose dependent decrease of TNF-alpha secretion. On the other hand, preincubation with anti-IL-10 monoclonal antibodies led to significant increase in TNF-alpha secretion in controls (median, 7,325 to 16,800 pg/mL; P = .002) but not in cells from cirrhotic patients (16,535 to 20,450 pg/mL; P = .14), abolishing the difference in TNF-alpha production between cirrhotic patients and controls. It is concluded that defective IL-10 secretion by monocytes from alcoholic cirrhotic patients could be involved in the characteristics TNF-alpha overproduction observed in this disease.

Adult↗
PubMed1995

[Spiral tomodensitometry of pancreatic calcifications].

Chronic pancreatitis is characterized by the formation of intraductal precipitates that may later grow and calcify, forming large stones. These calcified stones, representing almost all the calcifications visible in chronic pancreatitis, are located in the major pancreatic duct or in the secondary branches. During the past 10 years, new sophisticated endoscopic techniques have been developed to remove obstructing calculi from the main pancreatic duct. These techniques require an accurate evaluation of the location of the calculi, since calculi cannot be removed from secondary branches. Therefore, a new radiological approach has been developed, based on helicoidal scanning and multiplanar and tridimensional reconstructions of the calculi layout.

Calculi↗
PubMed1994

Interleukin-10 production during septicaemia.

Interleukin-10 is produced during incubation of human whole blood with bacterial lipopolysaccharide (LPS) and down-regulates tumour necrosis factor-alpha production in this in-vitro model of endotoxaemia. 39 out of 69 (57%) patients with gram-negative (n = 25) or gram-positive septicaemia (n = 44) had increased plasma interleukin-10 (range 12-2740 pg/mL), whereas interleukin-10 was undetectable in 29 out of 33 control patients without infection and in 20 healthy volunteers. Patients with septic shock (n = 21) had higher interleukin-10 (main 58 pg/mL) than septicaemic patients without shock (11 pg/mL, p < 0.001). We conclude that interleukin-10 is produced during sepsis and might be involved in the control of the inflammatory response induced by bacterial products.

Adult↗
PubMed1994

Systemic release of interleukin-10 during orthotopic liver transplantation.

Experimental and clinical observations indicate that the liver allograft is less immunogenic than other organ transplants and can promote immune tolerance. Because interleukin-10 recently emerged as a macrophage and T-cell-derived cytokine with potent immunosuppressive properties, we studied its production in 28 patients undergoing orthotopic liver transplantation. Plasma levels of immunoreactive interleukin-10 dramatically increased within 2 hr after liver allograft reperfusion, with peak levels ranging between 214 and 4998 pg/ml (median = 677 pg/ml). This systemic release of interleukin-10 was transient because it returned to low levels by 48 hr (range = 26 to 51 pg/ml). The higher interleukin-10 levels measured in right atrial blood as compared with portal blood indicated that interleukin-10 was most likely synthesized within the liver graft. To get insight into the cellular origin of interleukin-10, we also measured serum levels of interleukin-4 and interferon-gamma, both produced by T cells, and interleukin-8, a cytokine secreted by macrophages, in eight patients. Interleukin-4 and interferon-gamma levels remained undetectable in most of the patients, whereas interleukin-8 levels paralleled those of interleukin-10. Portal endotoxemia was probably not involved in interleukin-10 production because endotoxin levels remained low (< 20 pg/ml) before and after liver allograft reperfusion. Interleukin-10 plasma levels did not correlate either with cold ischemia time or with the occurrence of rejection episodes. We conclude that orthotopic liver transplantation is associated with a massive release of interleukin-10 and interleukin-8, most likely produced by allograft macrophages.

Adult↗
PubMed1994

Trypsin activity. A new marker of acute alcoholic pancreatitis.

A normal serum amylase level is found in up to 32% of patients with acute alcoholic pancreatitis. This underlines the need for more sensitive diagnostic tests in this frequent cause of pancreatitis. Animal and human studies have shown that chronic alcohol consumption leads to important modifications in trypsinogen metabolism. The present work has prospectively analyzed admission serum trypsin activity with a new biochemical test and usual markers such as amylase, lipase, and immunoreactive trypsin in 32 attacks of acute pancreatitis. Seventeen were due to alcohol and 15 to other causes, including 11 with gallstone pancreatitis. High trypsin activity (median: 235 units/liter; range: 165-853) was found in all patients with acute alcoholic pancreatitis even when the amylase level was normal on admission (3/17: 18%). Trypsin activity did not differ between nonalcoholic pancreatitis (N = 15): 84 units/liter (42-98), alcoholic controls (N = 15): 77 units/liter (40-122), and healthy controls (N = 62): 81 units/liter (15-143). The difference was not related to the severity of disease or circulating alpha 2-macroglobulin, alpha 1-protease inhibitor, or immunoreactive trypsinogen levels. Lipase/amylase ratio was less discriminant than trypsin activity between alcoholic and nonalcoholic diseases. We conclude that serum trypsin activity seems specific to acute alcoholic pancreatitis and should be included in new prospective studies assessing biochemical testing of alcohol-related pancreatic diseases.

Acute Disease↗
PubMed1994

Interleukin-6: an early marker of bacterial infection in decompensated cirrhosis.

Fifty-seven patients with decompensated cirrhosis were studied prospectively to assess the sensitivity and specificity of early clinical or biological signs of bacterial infection. Among them, 19 had proven infection on admission (7 spontaneous bacterial peritonitis, 5 bacteraemia, 3 urinary tract infections, 2 pneumonia, 1 dental abscess and 1 cholangitis). Fever, polymorphonuclear cell count, fibrinogen and C-reactive protein levels were found to be of little or no help in diagnosing bacterial infection on admission. Interleukin-6 plasma levels were, however, significantly different between infected (median: 1386 pg/ml, range: 237-20,000) and non-infected patients (median: 34 pg/ml, range: 0-4500, p < 0.00001). Levels above 200 pg/ml were always found in infected patients, giving a sensitivity of 100% and a specificity of 74%. C-reactive protein correlated weakly with interleukin-6 levels, indicating a defective acute-phase response in cirrhosis. Tumor necrosis factor alpha plasma levels were less sensitive (95%) and specific (68%) for the diagnosis of bacterial infection at a threshold of 50 pg/ml, but were more closely related to a poor patient outcome. In decompensated cirrhosis, interleukin-6 plasma levels on admission provided the most sensitive and specific tool for the diagnosis of bacterial infection.

Adult↗
PubMed1994

Transjugular intrahepatic portosystemic stent shunt as a rescue treatment after sclerotherapy failure in variceal bleeding.

BACKGROUND: Variceal bleeding carries high early mortality, especially after failure of conventional treatments such as endoscopic injection therapy. The present study analyses the efficacy of transjugular intrahepatic portosystemic stent shunt (TIPS) in cirrhotic patients after failure of sclerotherapy for variceal bleeding. METHODS: Twenty-four consecutive patients underwent TIPS in this indication. RESULTS: The procedure was successful in all patients, with reduction of size or disappearance of varices in 96% of them. Four patients (17%) developed encephalopathy and six (25%) rebled during the follow-up period (median 5 months; range 1-19). Thirty-day mortality was only 17% and 29% during the follow-up period. Deaths were mainly due to liver failure, especially after procedures performed in emergency. Significant decrease in liver function was observed in the days following the procedure. To maintain long-term patency of the shunt, revision was required in nine patients (38%). CONCLUSIONS: TIPS seems to be a promising salvage therapeutic procedure after failed sclerotherapy, but this needs to be addressed in controlled trials.

Esophageal and Gastric Varices↗
PubMed1993

Tumor necrosis factor alpha and interleukin 6 plasma levels in infected cirrhotic patients.

BACKGROUND: Patients with liver cirrhosis disclose both increased production and decreased metabolism of tumor necrosis factor alpha (TNF-alpha) and interleukin 6 (IL-6). The present study analyzes the characteristic pattern of these cytokines during sepsis in cirrhotics. METHODS: TNF-alpha and IL-6 plasma levels, measured during 15 days from the onset of cirrhotic decompensation or of the septic event, were compared between 14 infected patients with liver cirrhosis, 18 uninfected decompensated cirrhotic patients, and 35 septicemic patients devoid of liver disease. Cytokines were measured using immunoassays. RESULTS: In infected cirrhotics, initial levels of both TNF-alpha and IL-6 were significantly higher than in noninfected cirrhotic patients (P < 0.0001) or in septicemic patients devoid of cirrhosis (P < 0.001). Initial IL-6 plasma levels (threshold, 200 pg/mL) showed 89% specificity and 100% sensitivity in discriminating cirrhotic decompensation due to infection from that caused by other factors. TNF-alpha and IL-6 plasma levels remained significantly higher for many days in infected cirrhotic patients compared with the other two groups. CONCLUSIONS: Both the profoundly increased initial levels of TNF-alpha and IL-6 and their persistence over days after sepsis onset seem characteristic of the cirrhotic patients. The exact relationship between prolonged exposure to TNF-alpha and poor prognosis in these patients is unknown, but it might represent a unique opportunity for the use of anti-TNF-alpha antibodies during sepsis.

Aged↗
PubMed1992

Factors related to early mortality in cirrhotic patients bleeding from varices and treated by urgent sclerotherapy.

Variceal haemorrhage in cirrhotic patients carries a high early mortality even when balloon tamponade or emergency sclerotherapy are applied. The aim of this study to identify patients dying within six weeks of their first variceal haemorrhage. One hundred and twenty one patients with parenchymal cirrhosis presenting with the first variceal bleeding episode between June 1983 and December 1988 were studied. Nineteen patients were excluded for various reasons. Emergency sclerotherapy was carried out in cases of active bleeding or where there were endoscopic signs of recent bleeding, and then regularly repeated afterwards. Of the 24 variables studied and included in a multivariate analysis using a logistic regression model, three had an independent prognostic value: encephalopathy, prothrombin time, and the number of blood units transfused within the 72 hours of time zero. The subsequent regression equation was able to predict 89% of the patients who will die and 97% of the patients who will still be alive six weeks after their first variceal haemorrhage treated by sclerotherapy. Pugh score was less discriminatory than these last three variables in terms of accuracy of adjustment, goodness of fit to the model, receiver operating characteristic curves, and percentage correct prediction. To measure the accuracy of the prediction rule, our model was applied to another series of 28 cirrhotic patients admitted with their first variceal bleeding during the next period (January 1989 to May 1990). Death and survival were correctly predicted in respectively 82% and 94% of the cases. The use of this score is recommended for the selection of patients with high early mortality after variceal bleeding despite sclerotherapy, and for the design of new therapeutic trials.

Acute Disease↗
PubMed1992

Stenting in severe chronic pancreatitis: results of medium-term follow-up in seventy-six patients.

Between January 1985 and September 1989, 75 patients presenting with severe chronic pancreatitis with distal stricture and upstream dilatation underwent stenting of the main pancreatic duct (MPD) through the major papilla (n = 54) or minor papilla (n = 21) in order to drain the predominant duct through a 10F plastic prosthesis. All patients had undergone biliary and pancreatic sphincterotomy with a few cases of complications, and the majority (84%) also ESWL in the period from October 1987 onwards without complications. Relief of pain (94%) occurred parallel to a decrease in the MPD diameter. In a mean follow-up period of 37 months improvement of the nutrition status and relief of pain was seen. Clogging of these large plastic stents was treated by replacement or by another endoscopic or surgical procedure. Complications were treated endoscopically. Further measures necessary due to failure of stenting consisted of laterolateral pancreatico-jejunostomy in 15% of patients and placement of self-expanding 18F metal mesh stents in 29%. There was no mortality due to surgery. It is concluded that stenting of distal strictures in the MPD can lead to rapid resolution of pancreatic pain due to ductal hypertension and is the best means for determining the cause of pain, providing an alternative to surgery. Significant improvement of a stricture by prolonged stenting is however unusual, and such patients treated endoscopically require close follow-up with stent replacement approximately once a year.

Adult↗