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PubMedDate not supplied

Application of peroral cholangioscopy in an endemic area with high prevalence of hepatocellular carcinoma and choledocholithiasis.

BACKGROUND/AIMS: Peroral cholangioscopy with a mother-baby scope system has been introduced for two decades. The paper presents the experience of peroral cholangioscopy at a university hospital in Taiwan where the prevalence of hepatocellular carcinoma and choledocholithiasis was high. METHODOLOGY: A total of 27 sessions of peroral cholangioscopy were performed in 26 patients during a period of 4 years. Of them, 20 patients were for diagnosis and the rest 6 for removing the retained biliary stones. RESULTS: The overall successful rate was 96.3%. The post-procedure complication rate was 11.5% with 2 cholangitis and 1 gram-negative septicemia. There were a total of 19 successful diagnostic sessions. These resulted in definite histological diagnosis in 5 patients and more precise diagnoses subsequently confirmed by surgery in 5 patients. In the remaining 9 patients with tentative diagnoses, 5 confirmed their diagnoses but 4 patients changed their diagnoses after peroral cholangioscopy. By this procedure, hepatocellular carcinoma and choledocholithiasis can be well identified and differentiated. CONCLUSIONS: Peroral cholangioscopy is a safe and valuable modality in diagnosing and treating difficult biliary tract disease when handled with care. It is particularly useful in an endemic area with high prevalence of hepatocellular carcinoma and choledocholithiasis.

Adult↗

PubMed2000

Long-term follow-up after treatment of Mirizzi syndrome by peroral cholangioscopy.

BACKGROUND: The standard treatment for Mirizzi syndrome is surgical, although endoscopic and percutaneous management have also been described. The aim of this study was to evaluate the usefulness of shock wave lithotripsy combined with peroral cholangioscopy and its long-term outcome in patients with Mirizzi syndrome. METHODS: The records of 25 patients with Mirizzi syndrome who underwent endoscopic treatment between April 1990 and November 1998 were retrospectively reviewed. Shock wave lithotripsy was performed under direct vision with a "mother-baby" endoscope system in 2 patients with type I and 23 with type II Mirizzi syndrome (12 men and 13 women, mean age 60 years). Follow-up data were obtained from clinical records or through telephone interviews. RESULTS: In the two patients with type I, the cholangioscopic approach failed and both patients underwent open cholecystectomy. The 23 patients with type II were all successfully treated with shock wave lithotripsy alone. The cholangioscopic approach was unsuccessful in the treatment of residual gallbladder stones. Follow-up data were obtained in all but one patient (mean 43.6 months, range 4 to 103 months). Of the 23 patients with type II, 12 with no gallbladder stones had remained asymptomatic during the follow-up period. Of the 6 patients with type II with large residual gallbladder stones, 4 had acute cholangitis due to stone migration 6, 9, 28, and 34 months after endoscopic treatment. Two patients died during the follow-up period, one of non-biliary causes and the other of coexistent gallbladder carcinoma. CONCLUSIONS: Endoscopic treatment of Mirizzi syndrome using peroral cholangioscopy is a safe and effective alternative to surgery, especially in patients with the type II syndrome. A favorable long-term outcome depends on the absence of large residual gallbladder stones.

Adult↗

PubMed2005

Host TNF-alpha-1031 and -863 promoter single nucleotide polymorphisms determine the risk of benign ulceration after H. pylori infection.

OBJECTIVES: This study tested whether host genotypes of the tumor necrosis factor-alpha (TNF-alpha) promoter single nucleotide polymorphism (SNP) could determine clinical and histological outcomes after Helicobacter pylori infection. METHODS: A total of 524 dyspeptic patients, 424 with and 100 without H. pylori infection, were checked for TNF-alpha promoter SNP over the locus on -1031(T/C), -863(C/A), -857(C/T), -806(C/T), and -308(G/A) by sequence-specific oligonucleotide probe. Each patient received panendoscopy to take gastric biopsy to detect H. pylori infection and its related histology using the updated Sydney's system. Gastric TNF-alpha expressions were stained by immunohistochemistry. RESULTS: In H. pylori-infected patients, -1031C or -863A carriers of TNF-alpha promoter had more severe gastric neutrophil infiltration and TNF-alpha gastric staining than individuals with -1031TT or -863CC genotype, respectively (p<0.05). The multivariate logistic regression verified both -1031C and -863A carriers were independent risk factors to have duodenal ulcers and gastric ulcer without IM in the H. pylori-infected hosts (p<0.05). As compared to -863CC and -1031TT genotype combinations, the ulcer risk after H. pylori infection was 2.46 (95% CI: 1.32-4.59, p<or=0.00001) for the carriers with either -1031C or -863A allele, and even elevated to 6.06 (95% CI: 3.57-10.21, p<or=0.00001) for the individuals harboring both -863A and -1031C alleles. For patients with gastric ulcer, the 863CC genotype had a higher rate to have intestinal metaplasia than -863A carrier (p<or=0.005). CONCLUSIONS: TNF-alpha-1031 and -863 promoter SNP should be novel host factors to determine the gastric inflammation and risk of peptic ulceration upon H. pylori infection.

Biopsy↗

PubMed2003

Feasibility study using a new small electronic pancreatoscope: description of findings in chronic pancreatitis.

BACKGROUND AND STUDY AIMS: Numerous images characteristic of chronic pancreatitis have been obtained with fiberoptic peroral pancreatoscopy systems. However, the resolution of these images is inferior to that obtained with peroral electronic pancreatoscopy (PEPS). Clearer images of the pancreatic duct with chronic pancreatitis have now been documented, in some cases using PEPS alone. The significance of this finding is reported here. PATIENTS AND METHODS: A total of 42 PEPS procedures were carried out in 36 patients with chronic pancreatitis, without sphincterotomy or balloon dilation of the papilla of Vater. Using endoscopic retrograde pancreatography, the patients were classified as having equivocal (n=5), mild (n=5), moderate (n=15), or marked (n=11) degrees of chronic pancreatitis. The insertion rate with PEPS was 90 % (38 of 42 procedures), and it was ultimately possible to examine five, three, 13, and 11 patients in each group, respectively. RESULTS: Images of turbid pancreatic juice, protein plugs of various shapes, pancreatic calculi, indistinct vascular markings, whitish mucosa, local redness, scattered redness, disappearance of the fold, deformation of the fold, irregularly dilated lumen, and stenosis were found to be characteristic of chronic pancreatitis. These images were obtained using PEPS. CONCLUSIONS: PEPS proved to be a feasible new technique for diagnosing chronic pancreatitis, and it was able to detect abnormal findings more clearly than other imaging methods.

Aged↗

PubMed2002

ASGE guidelines for the appropriate use of upper endoscopy: association with endoscopic findings.

BACKGROUND: This prospective study examined the appropriate use of EGD in an open-access system with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and determined whether the ASGE guidelines were associated with relevant endoscopic findings. METHODS: In a cohort of 1777 consecutive patients referred for open-access EGD, the proportion of patients who underwent EGD for appropriate indications was prospectively assessed. The relationship between appropriateness and the presence of clinically relevant endoscopic diagnoses was assessed by calculating (1) the likelihood ratio, positive and negative, of the indications; and (2) the change in the probability of relevant endoscopic diagnoses in the presence of the ASGE criteria. RESULTS: The rate for EGDs "generally not indicated" was 15.6%. Relevant endoscopic diagnoses were present in 47.4% of cases with ASGE indications versus 28.8% of patients without appropriate indications as defined by the ASGE criteria (OR: 2.23; 99% CI [1.55, 3.22]; p < 0.01). A similar difference was observed for erosive gastritis (OR: 1.86; 99% CI [1.17, 2.95]; p < 0.01), erosive esophagitis (OR: 1.48; 99% CI [0.87, 2.52]; p < 0.05), and Barrett's esophagus (OR: 9.76; 99% CI [0.72, 132]; p < 0.05). The pretest probability of finding a relevant endoscopic diagnosis was modified slightly when an ASGE indication(s) was present and decreased markedly when ASGE criteria were absent. CONCLUSIONS: The use of the ASGE guideline for appropriate indications for EGD can improve patient selection for the procedure. However, to avoid missed diagnoses of serious disease, use of the guidelines must be tailored to the specific clinical setting.

Adolescent↗

PubMed1991

Intraoperative use of a 2-mm choledochoscope for the exploration of small bile ducts and the pancreatic duct.

Intraoperative visualization of the biliary and pancreatic ducts can be difficult in a nondilated system. Very small extra- and intrahepatic bile ducts occasionally require visualization but do not admit the traditional 6.5-mm intraoperative flexible choledochoscope. We have prospectively examined the use of a 2-mm choledochoscope for the intraoperative evaluation of the biliary and pancreatic ducts in 36 patients. In 27 patients, the choledochoscope was advanced through the cystic duct stump for examination of the common bile duct following cholangiography. The scope was successfully passed into the cystic duct stump and into the common bile duct in 76 per cent of patients. Inability to pass the scope through the cystic duct was usually due to acute angulation of the cystic duct/common duct junction. In an additional five patients, intraoperative cholangiography revealed a filling defect in a very small duct. A choledochotomy was made and the 2-mm choledochoscope was used to exclude the presence of stones in a small bile duct. In four patients the choledochoscope was used during a Puestow procedure to visualize and help extract stones in the tail and head of the gland. No complications occurred in these patients due to the use of the choledochoscope. We conclude that the 2-mm choledochoscope aids in internal visualization of small intra- and extrahepatic bile ducts and the pancreatic duct. It may be useful as an adjunct to cholangiography in determining the nature of filling defects.

Bile Duct Diseases↗

PubMed1989

Evaluation of the portal hypertensive patient.

Portal hypertension is characterized by a chronic increase in portal venous pressure. This is initiated by an increased vascular resistance to portal blood flow. In advanced stages, however, blood flow increases and contributes to worsen and maintain portal hypertension. Increased pressure and blood flow within the portal system promotes the appearance and dilation of portal-systemic collaterals and oesophageal varices, which are responsible for the main complication of portal hypertension: massive gastrointestinal haemorrhage. In recent years there have been several major innovations in the evaluation of portal hypertension. These include the application of new endoscopic, ultrasonographic and haemodynamic techniques that allow a better evaluation of the portal hypertensive patient, especially when prophylactic medical therapy is considered. Ultrasonography is very useful to assess the patency of the portal vein. The association of a pulsed Doppler flowmeter increases its accuracy and allows the non-invasive estimation of the direction and magnitude of portal blood flow. In addition to the measurement of portal pressure, measurement of azygos venous blood flow has proven very useful in the haemodynamic evaluation of portal hypertension. Azygos blood flow represents an index of blood flow through gastro-oesophageal collaterals and varices draining in the azygos vein. Its main application has been the assessment of the effects of pharmacological therapy. Endoscopic measurements of variceal pressure, either by direct puncture or using non-invasive pressure gauges, have contributed significantly to the understanding of the mechanism of variceal haemorrhage. This technique allows the calculation of the variceal wall tension as the product of the transmural pressure at the varices and the radius of the varix.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Pressure↗

PubMed2003

Involvement of the biliary system in autoimmune pancreatitis: a follow-up study.

BACKGROUND & AIMS: The aim of this study was to define the bile duct changes associated with autoimmune pancreatitis. METHODS: Eight patients with autoimmune pancreatitis were followed for a mean of 4 years. The clinical features of these patients, including extrapancreatic bile duct changes, were examined by using biochemical parameters and several imaging modalities. Pathologic features of the pancreas and liver were examined by using the biopsy specimens of 7 patients. RESULTS: Diffuse or focal narrowing of the main pancreatic duct was observed in all patients. Histologic examination of the pancreas showed lymphoplasmacyte infiltration with severe fibrosis and acinar cell depletion. In 6 patients extrapancreatic bile duct changes such as stricture of the bile duct at hilus or intrahepatic area were observed. In 2 patients abnormalities in the bile duct and pancreas were detected simultaneously at diagnosis, and changes in the bile duct were observed later in 4 patients. Lymphoplasmacyte infiltration and fibrosis were observed in the portal area of all 7 liver biopsy samples. Five of the patients with bile duct changes received steroid therapy, and the pathological changes improved. CONCLUSIONS: Extrapancreatic bile duct changes are frequently associated with autoimmune pancreatitis. Similar pathogenic mechanism might produce the biliary tract and pancreatic abnormalities in autoimmune pancreatitis resulting in a similar histopathology in the liver and pancreas and response to steroid therapy.

Aged↗

PubMed1996

"Mother-baby" biliary endoscopy: the University of Chicago experience.

OBJECTIVE: The "mother-baby" technique of peroral cholangioscopy is a relatively recent development in biliary endoscopy and permits direct visualization of the biliary tree. This paper presents the experience of one institution with this new technique. METHODS: We used the Olympus mother-baby endoscopy system at the University of Chicago and at one of its affiliated hospitals to examine and treat selected lesions in the biliary tree that had eluded successful diagnosis or treatment by standard means. In addition, we used the baby endoscope alone through surgically created percutaneous tracts to treat selected patients with retained stones. RESULTS: From July 1990 to June 1993, peroral cholangioscopy was performed 18 times in 12 patients at the University of Chicago and affiliated hospitals. The baby endoscope was successfully passed into the bile duct in 15 of 18 cases (83.3%). Additionally, the baby endoscope alone was used through a T-tube or cholecystostomy tract 10 times in six patients. Complications occurred in two patients and were minor; there were no fatalities. With refinement of technique, successful passage of the baby endoscope was accomplished in 100% of patients undergoing peroral cholangioscopy. CONCLUSIONS: Direct visualization of the biliary tree with the ability to sample (brush, biopsy) or treat (basket removal, electrohydraulic or laser lithotripsy) lesions significantly aided in the care of all patients in whom the baby endoscope was successfully passed by providing the correct diagnosis and, when appropriate, by allowing definitive treatment of lesions. The eventual role of this technique in the current cost-conscious climate is unclear, but at present it should be limited to selected referral centers.

Adult↗

PubMed2006

Morphological changes of the upper gastrointestinal tract mucosa and Helicobacter pylori infection in HIV-positive patients with severe immunodeficiency and symptoms of dyspepsia.

BACKGROUND: HIV infection causes progressive immune defense system dysfunction, including the gastrointestinal (GI) tract. The aim of the study was to evaluate the morphological changes in the upper-GI tract mucosa in HIV-infected patients in relation to the degree of immunodeficiency, presence of H. pylori, fungal colonization, and antiretroviral treatment (HAART). MATERIAL/METHODS: One hundred forty-six patients (94 HIV positive, 52 HIV negative) with dyspeptic symptoms were evaluated by upper GI endoscopy and biopsy. The HIV-infected were divided into two groups: 47 patients with CD4+ count >200/mm(3) and 47 with severe immunodeficiency (CD4+ count <200/mm(3)); 42 of the total patients were treated with HAART. Gastric biopsies for histopathology and urease test, esophageal swabs, and gastric aspirates for mycological evaluation were taken. RESULTS: The HIV-infected patients with severe immunodeficiency had a lower prevalence of H. pylori infection and active chronic gastritis in the gastric antrum compared with the other HIV-infected patients and controls (H. pylori in 40%, 72%, and 69%, respectively; p<0.05). Mycotic esophagitis and mycotic colonization of the stomach were more frequent in patients with severe immunodeficiency. The prevalence of gastric mucosa changes was not different between the patients treated and not treated with HAART; H. pylori infection was less frequent in HIV-infected patients treated with HAART (p<0.05). CONCLUSIONS: In severely immunodeficient patients with dyspeptic symptoms, the prevalence of H. pylori and active chronic gastritis in the gastric antrum is much lower than in HIV-negative patients. H. pylori infection is less frequent in patients treated with HAART.

Adult↗

PubMed2005

Comparison of the grading of esophageal varices by transnasal endoluminal ultrasound and esophagogastroduodenoscopy.

BACKGROUND & AIMS: Esophagogastroduodenoscopy (EGD) is the current standard for evaluating esophageal varices, yet there is no universally accepted system of grading varices endoscopically and several studies have shown interobserver variability of endoscopic grading. High-resolution endoluminal ultrasound 20 MHz (HRES) has been shown to detect varices accurately and can be performed without sedation. Our aim was to compare the detection of esophageal varices by transnasal HRES and EGD. METHODS: We prospectively studied 37 cirrhotic patients being evaluated for esophageal varices. HRES was used to measure the largest esophageal variceal diameter and then EGD was performed. Photographs were taken for both procedures. Three blinded investigators graded the EGD photographs at 2 periods. End points were as follows: (1) the correlation of HRES variceal diameter and EGD grading of varices, and (2) the assessment of interobserver and intraobserver variation in varix grading by EGD. RESULTS: The correlation between the transnasal HRES and EGD was .63, with a 95% confidence interval of .37-.80. The HRES detected early varices that were not seen by EGD. The interobserver correlation for EGD scoring was .87 or greater in all comparisons and the intraobserver correlation was .91 or greater. CONCLUSIONS: In conclusion, there is a significant correlation between transnasal HRES size measurement of esophageal varices and EGD. HRES is much more sensitive in detecting early esophageal varices and may not require sedation, suggesting that it may be more tolerable to patients and is worth further study.

Adult↗

PubMed1996

Is portal hypertension due to liver cirrhosis a major factor in the development of portal hypertensive gastropathy?

OBJECTIVES: The gastric mucosa of patients with portal hypertension frequently manifests changes in its appearance that are readily identifiable by endoscopy. Many of these can be sources of bleeding, and some imply the presence of systemic disease. Although portal hypertension is critical in development of portal hypertensive gastropathy (PHG), the role that other factors might play in its pathogenesis is uncertain. METHODS: Four groups of subjects were studied prospectively: 37 with portal hypertension due to cirrhosis, 26 noncirrhotic subjects with portal hypertension due to extrahepatic portal vein obstruction (PVO), nine cirrhotic patients with extrahepatic PVO, and 57 control subjects. The diagnosis in each case was based on a combination of clinical data, needle liver biopsy, ultrasonography, splenoportography, and upper GI endoscopy. RESULTS: Snake skin, scarlatina rash, diffuse hyperemia, and diffuse bleeding were frequent endoscopic gastric findings in cirrhotic patients. These findings were seen less frequently in noncirrhotic patients with portal hypertension due to PVO than in cirrhotic patients (p< 0.0001). The highest incidence was seen in cirrhotic patients with PVO (P< 0.001). Positive correlations existed among the endoscopic findings, the clinical estimate of the cirrhosis severity (Child-Pugh grade), and the size and appearance of esophageal varices (Beppu score). No endoscopic findings of the gastric mucosa enabled one to distinguish between groups. Hypergastrinemia was present in cirrhotics with and without PVO but not in noncirrhotic patients with portal hypertension resulting from isolated PVO. CONCLUSION: These findings suggest that the endoscopic findings of PHG are affected by the severity of the underlying liver disease and the presence or absence of coexisting PVO. There is no association between PHG and the presence of gastric varices. Thus, the development of the gastric lesions characteristic of PHG requires not only portal hypertension but also some other consequence of parenchymal liver disease.

Adult↗

PubMed2005

Diagnosis of esophagogastric tumors.

With regard to esophageal tumors, important reports on several topics have been published recently. 1) The place of endoscopic ultrasonography (EUS) as the best locoregional staging technique for cancer of the esophagus has been further consolidated. The addition of fine-needle aspiration makes EUS more sensitive than computed tomography (CT) and more accurate than CT or EUS alone for nodal staging. 2) High-resolution endoscopy with chromoendoscopy has been found to be very effective for mucosal lesions, but not for submucosal lesions. In combination with EUS, the sensitivity for submucosal tumors increases up to 60 %. 3) Autofluorescence-guided biopsy has been reported to be a good tool for detecting high-grade dysplasia. A narrow-band imaging system improved the overall accuracy for depth of invasion. 4) The incidence of hypopharyngeal cancer increases after resection for esophageal carcinoma. Patients with a scattered staining pattern after application of Lugol's solution are more prone to develop upper lesions. 5) Fluorescence imaging makes it possible to detect low-grade intraepithelial neoplasia in Barrett's mucosa, with fewer biopsies. 6) Patients with Barrett's esophagus with a length of over 3 cm had a significantly greater prevalence of dysplasia in comparison with those in the whom the Barrett's segment was shorter than 3 cm (23 % vs. 9 %, P = 0.0001). With regard to gastric tumors, 1) Helicobacter pylori eradication can significantly reduce the development of gastric cancer, but only in patients without precancerous lesions. 2) Intestinal metaplasia types II and III have been shown to have a higher rate of progression to low-grade dysplasia than type I. 3) With regard to screening in asymptomatic individuals, serum pepsinogen may represent an alternative to conventional fluoroscopy methods. 4) In patients who have undergone esophagectomy for esophageal cancer, annual follow-up endoscopies are vital for detecting early secondary gastric cancer and ulcerations in which curative treatment is possible. 5) High-resolution endoscopy allows more precise diagnosis of early gastric cancer. The presence of irregular minute vessels and variations in vessel caliber were found to be specific of early gastric cancer. The small regular pattern of sulci and ridges was observed significantly more frequently in differentiated carcinoma than in undifferentiated carcinoma. 6) Infrared-ray electronic endoscopy combined with indocyanine green injection appears to be effective in detecting sentinel nodes that contain metastases in patients with gastric cancer. 7) Gastric adenocarcinoma was found to show specific changes in the fluorescence spectra emitted, in comparison with normal gastric mucosa. However, there was wide variation in the emitted autofluorescence spectra in gastric cancer with signet-ring cells in comparison with normal mucosa.

Endoscopy, Digestive System↗

PubMed2000

Effect and outcomes of the ASGE guidelines on the periendoscopic management of patients who take anticoagulants.

OBJECTIVE: In December 1997, the American Society of Gastrointestinal Endoscopy (ASGE) issued guidelines regarding periendoscopic management of patients who take anticoagulants. They recommended that physicians substitute heparin for warfarin in their patients who have highly thrombotic conditions (e.g., a mechanical valve in the mitral position), and who will undergo high-risk procedures (e.g., polypectomy). The purpose of this study was to assess whether patient outcomes and anticoagulant management changed after the publication of the 1997 guidelines. METHODS: We collected utilization data on all 104 patients at the Veterans Affairs Palo Alto Health Care System who were taking chronic warfarin therapy and who underwent endoscopic procedures during the study period (1996-1999). These patients underwent 99 colonoscopies, 63 upper endoscopies, and nine endoscopic retrograde cholangiopancreatographies. According to the ASGE guidelines, 18 of these patients had highly thrombotic conditions, whereas the remaining 86 patients had relatively low thrombotic conditions. We calculated their costs for intravenous or subcutaneous heparin therapy from the perspective of society. We followed-up all patients for 3 months, to determine the incidence of thrombotic and hemorrhagic outcomes. RESULTS: No patient suffered a thromboembolism or a hemorrhage; thus, the adverse-event rate (95% confidence interval) was 0% (0-3%). As recommended by the ASGE guidelines, all five (100%) patients who had highly thrombotic conditions had heparin substituted for warfarin before undergoing high-risk procedures. This strategy was also followed in 44 (27%) of the 166 procedures in other patients: 16 high-risk procedures in low-risk patients, and 28 low-risk procedures (in 20 low-thrombotic patients and in eight high-thrombotic patients). There was no significant difference between the management of any patients before and after the publication of the guidelines. The average cost per course of heparin therapy (typically 2 days intravenous heparin preprocedure, and 3 days heparin administered subcutaneously postendoscopy) was $1684. In all, 44 (90%) of 49 courses of heparin substituted for warfarin therapy were not recommended by the guidelines. CONCLUSIONS: Patients treated by the ASGE guidelines had the same 0% rate of thrombosis as patients who received periendoscopic heparin outside of the guidelines. Following the ASGE guidelines in all patients would have reduced the use of heparin therapy by 90%, for a net savings of $74,100.

Aged↗

PubMed1991

[Clinical and experimental studies on stone detectability of cholangiography and choledochoscopy. Prevention of retained biliary-tract stones].

UNLABELLED: Preoperative diagnostic accuracy was significantly improved following a recent development of diagnostic imaging techniques. However, the incidence of retained biliary tract stones is far from satisfactory low. Retrospective studies on operative and postoperative cholangiography, and choledochoscopy were carried out to determine the limitation of each modality in preventing the retained biliary tract stones. The effectiveness of postoperative stone extraction technique for retained biliary tract stones was reevaluated by a follow up study of 213 cases with retained biliary tract stones in which complete removal of the stones was considered to be successful. Finally, a radiological experimental study concerning stone detectability was carried out using phantom system. CONCLUSION: 1) In the retrospective study of operative cholangiography, stones were not demonstrated on cholangiograms in 78 out of 167 cases, although they were detected and extracted by postoperative choledochoscopy. The main causes of the failure of cholangiography were the administration of highly concentrated contrast material (47.4%) and incomplete filling of whole ducts (26.9%). Therefore, the further development for the detection of these stones by operative cholangiography should be desired. 2) In the experimental study, it was clarified that complete filling of the ducts with 30% or 20% contrast materials was essential in normal size or dilated ducts respectively in order to detect small size stones. Moreover, the author emphasized that it is important to take two photographs, one is taken at proper voltage and the other at voltage 10 kVp. Higher in order to demonstrate whole stones whose sizes are varied. 3) Stone detectability was improved to 87.1% by using both operative cholangiogram and choledochoscopy. 4) Routine use of postoperative choledochoscopy at the time of T-tube removal is essential, because stone not detected by T-tube cholangiography were found endoscopically in 2.2% of cases with retained stones. 5) In the follow-up study, a good result was obtained in the cases in which complete stone extraction was considered to be successful by postoperative choledochoscopy. However, reoperation was found to have been performed in 13 cases, because of recurrent or retained stones. Of them three cases were judged to be recurrence. In the other 10 cases, the stones were defined as overlooked stones by postoperative choledochoscopy.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗

PubMed2003

[Impact of long-term systemic glucocorticoid therapy for bronchial asthma on the occurrence and course of peptic ulcer].

The study was undertaken to examine the incidence and specific features of peptic ulcer (PU) of the gastroduodenal area (GDA) in bronchial asthma (BA) and the impact of long-term oral maintenance therapy with systemic glucocorticosteroids (GCS) on the occurrence and course of peptic ulcer. Among the 260 examined patients with BA, GDA PU was revealed in 70(26.9%). The commonest site of an ulcerative process in the duodenum (90%) and its frequent combination with reflux esophagitis (84.1%) are noteworthy, which is likely to import some specific features to the clinical picture of GDA PU in BA. The latter is characterized by mild pain and a predominance of dyspepsia, which should be taken into account in assessing the clinical picture in patients with BA when there is a high risk for PU and in defining indications for esophagogastroduodenoscopy. The clinical and endoscopic features of the course of PU in patients with comorbidity were analyzed in relation to the use of GCS therapy. The analysis revealed that the incidence of PU did not depend on the severity and type of BA and on the use of GCS therapy. The study failed to provide evidence for the generally accepted idea of the leading role of GCS in the development of PU in BA. There was no significant negative impact of long-term small-dose GCS therapy on the clinical and endoscopic picture of PU in BA. The findings suggest that in BA, favorable conditions arose for realizing the predisposition to PU, which makes it necessary to carry out further studies to reveal the possible mechanisms that are responsible for the formation of concomitant diseases; this may be of fundamental importance in developing pathogenetically substantiated therapy for the above category of patients.

Adult↗

PubMed2001

Surveillance of pre-malignant disease of the pancreatico-biliary system.

Technical advancements in ultrasonography, contrast-enhanced computed tomography and magnetic resonance imaging, as well as the wider availability of these ultramodern imaging techniques, have resulted in the early detection and a better classification of various asymptomatic and symptomatic pancreatico-biliary lesions. Pre-malignant biliary and pancreatic lesions are rare disorders, and no clear data are available to define their malignant potential. Because of the lack of controlled epidemiological data, the time span for malignant transformation and its frequency cannot be defined in the majority of these lesions. Adenomyomatosis of the gallbladder and gallbladder polyps larger than 10 mm should be treated by cholecystectomy even in asymptomatic patients because of an increased risk of malignant transformation. Chronic cholangitis, primary sclerosing cholangitis and choledochal cysts are also pre-malignant conditions. The timing of surgery, once it is advised for a pre-malignant condition that is still benign, should, however, be individualized to the particular patient situation. In patients with chronic pancreatitis, surgery may be indicated for disease-related complications. In as much as chronic pancreatitis predisposes to a higher risk of pancreatic cancer, any suspicion of malignancy should warrant a surgical exploration. Intraductal papillary tumours and mucin-producing pancreatic tumours are other pre-malignant pancreatic lesions whose malignant potential cannot be precisely determined pre-operatively. They should be resected in situations where there is a high degree of suspicion even without a clear objective diagnosis. In conclusion, pre-malignant hepato-biliary and pancreatic lesions of uncertain pathology should undergo early resection in view of treatment limitations and the dismal prognosis of established cancers. While hepato-biliary and pancreatic surgery is nowadays performed in specialized centres, with a low post-operative morbidity and mortality, it is equally important to understand that observation alone with regular computed tomography or magnetic resonance imaging control can no longer be recommended in the management of these lesions.

Biliary Tract Neoplasms↗

PubMed1999

Endoscopic management of gastrointestinal foreign bodies in children.

Endoscopic removal of foreign bodies (FBs) is an important part of therapeutic endoscopy in children. Children most often ingest coins, pins, keys, round stones or marbles, nails, rings, batteries and toys. Coins were the most common FB in the pediatric series of 139 children, who underwent endoscopic removal in Seoul National University Children's Hospital, Korea. The management of FBs depends on the type (sharp or dull, pointed or blunt, and toxic or nontoxic) and the size, along with the location of FB in the gastrointestinal tract. The endoscopist should decide whether endoscopic intervention is necessary and how urgently it has to be done. Indications for removal of FBs from the gastrointestinal tract in children are 1) All esophageal FBs, 2) Gastric or duodenal FBs if they are sharp or pointed, of more than 4 cm long or 2 cm wide in young infants and children; if containing toxic substances and if blunt objects remaining after 2 week observation in the stomach or 1 week observation in the duodenum. Esophageal FBs should be removed within 24 hours because of the risks of perforation and serious fistula formation. Disk batteries can cause corrosive injury to the esophagus within 4 hours. Coin retrieval can be done using the W-shape FB grasping forceps without an endotracheal general anesthesia. Blunt FBs, such as marbles can be best removed with a stone retrieval basket, which can be made from a condom. Disk batteries cannot be grasped with the FB forceps and snares, but very safely with the powerful magnet attached to the tip of the scope. Overtubes and protective rubber hoods are useful for removing sharp or pointed objects. It is important to test the available grasping accessories on a duplicate of the FB as a "dry run" to determine which accessories will grasp the FB securely.

Age Distribution↗