EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent placement should replace PTBD after ERCP failure in patients with distal tumoral biliary obstruction: a large real-life study.

AIMS: In cases of malignant distal biliary obstruction, ERCP is the preferred technique for bile duct drainage. In case of failure, the alternative techniques are percutaneous transhepatic biliary drainage (PTBD) and more recently endoscopic ultrasound-guided biliary drainage. A new type of stent called the electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) has been developed to enable the performance of biliary-enteric anastomosis under EUS-guidance in a single step, without prior bile duct puncture or the need for a guidewire. The aim of our study was to compare the real-life efficacies of PTBD and EUS-BD with the EC-LAMS for cases of ERCP failure in patients with malignant biliary obstruction. METHODS: We performed a monocentric retrospective study comparing PTBD and EUS-BD with the use of electrocautery-enhanced lumen-apposing metal stent in the context of a malignant distal biliary obstruction after ERCP failure. RESULTS: 95 patients were included (50 in EUS-BD group and 45 in PTBD group). The main etiology of malignant obstruction was adenocarcinoma of the head of pancreas (85%). There was a significant difference in favor of endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced lumen-apposing metal stent for the following criteria: clinical success: 89.3% vs. 45.5%; p < 0.0001; procedure-related adverse event rate: 2.12% vs. 22.7%; p = 0.003; duration of post-drainage hospitalization: 3.5 vs. 8.2 days; p < 0.0001, overall survival (median survival): 118.2 vs. 42 days; p = 0.012, overall cost of the strategy per patient: 5098 vs. 9363 euros; p < 0.001. CONCLUSION: Our results are in favor of EUS-BD using electrocautery-enhanced lumen-apposing metal stent in case of ERCP failure for a distal tumor biliary obstruction. Operators performing ERCP for distal tumor biliary obstruction must learn this backup procedure because of its superiority over percutaneous transhepatic biliary drainage in terms of clinical success, safety, cost, and overall survival.

Adherence to online monitoring of patient-reported outcomes by patients with chronic inflammatory diseases: a feasibility study.

OBJECTIVES: The objective of this report is to investigate the feasibility of collecting patient-reported outcomes (PROs) via e-questionnaires delivered to patients with chronic inflammatory diseases (CIDs). METHODS: Consecutive outpatients with a confirmed diagnosis of systemic lupus erythematosus, primary Sjögren's syndrome or inflammatory bowel disease were followed at two medical departments. Patients received monthly e-mails containing the SF36, Hospital Anxiety and Depression scale and an analogue symptom scale over a six-month period. Participation rate, socio-demographic characteristics and patients' satisfaction were analysed. RESULTS: A total of 128 patients were included (79% female; mean age: 42 ± 12 years). Eighty-two per cent of questionnaires were returned. The monthly participation rate ranged from 89% to 77%, with a six-month attrition rate of 13%. The mean completion rate of questionnaires was 98%. Factors significantly associated with increased answer rate were: married/couple status, greater number of children at home and previous participation in online surveys. The main reasons for non-response were: 'too busy to participate' (35%) and 'away from home Internet access' (31%). Overall, 68% of the participants found the study convenient and 96% agreed to continue at a monthly or bimonthly frequency. CONCLUSION: Online home self-assessment of PROs was feasible in the setting of CIDs. Patients were satisfied and willing to continue the survey. The Internet allows immediate and sophisticated presentation of PROs to clinicians. Future studies are warranted to determine how PRO monitoring may contribute to routine care in CIDs and other diseases.

Miss rate for colorectal neoplastic polyps: a prospective multicenter study of back-to-back video colonoscopies.

BACKGROUND AND STUDY AIM: Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination. PATIENTS AND METHODS: 294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas. RESULTS: The miss rates for polyps, adenomas, polyps > or = 5 mm, adenomas > or = 5 mm, and advanced adenomas were, respectively, 28 %, 20 %, 12 %, 9 % and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 % and 26 % but the corresponding rates were 23 % and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (> or = 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate. CONCLUSIONS: We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.

Nutritional status is a prognostic factor for survival in ALS patients.

OBJECTIVE: To evaluate the occurrence of malnutrition in patients with ALS, to assess the relation of malnutrition to the neurologic deficit, and to determine the impact of nutritional status on patient survival. BACKGROUND: Although ALS may be associated with significant malnutrition, the relative impact on patient survival has not yet been well established. METHODS: In a prospective 7-month study of 55 ALS patients in a referral neurology practice, nutritional status was assessed by calculating body mass index. Neurologic evaluation includes four functional scores and identifies the form of disease onset. Slow vital capacity (VC) was also measured. RESULTS: Occurrence of malnutrition in patients studied was 16.4%. Survival (using the Kaplan-Meier method) was worse for malnourished patients (p < 0.0001), with a 7.7-fold increased risk of death. Using multivariate analysis, only reduced VC (p < 0.0001) and malnutrition (p < 0.01) were found to have significant independent prognostic value. The degree of malnutrition is independent of neurologic scores and of forms of ALS onset. CONCLUSION: Nutritional surveillance of ALS patients is very important, both in bulbar-onset and spinal-onset patients.

Central and peripheral effects of prostaglandin E2 and enprostil on exocrine pancreatic secretion in rats.

Prostaglandin E2 (PGE2) has been reported to exert some centrally mediated effects on intestinal motility and secretion and on gastric secretion, but it is not known whether such central effects exist on pancreatic secretion. The central and peripheral effects of PGE2 and enprostil, a long-acting, potent PGE2 analogue, were studied in conscious and anesthetized rats fitted with pancreatic fistulae. In chronically implanted, conscious rats, PGE2 inhibited the secretion of fluid, bicarbonate, and total protein in the pancreatic juice, both after i.v. or intracerebroventricular (icv) injections. The maximal inhibition was similar after both injection procedures (about 45% for fluid and bicarbonate and 60% for protein), but the potency of PGE2 was three to 10 times greater by the icv than the i.v. route. Enprostil also inhibited pancreatic secretion in a dose-related way. The maximal inhibition was larger than after PGE2 injection (about 70% for fluid and bicarbonate and 90% for protein). The potency of enprostil was five to 10 times lower by the icv than by the i.v. route. The diversion of gastric secretion suppressed the effect of icv PGE2 on fluid and bicarbonate output but not on protein and did not change the effect of enprostil on all the variables of pancreatic secretion. Adrenergic antagonists did not suppress the effect of icv PGE2 or enprostil on pancreatic secretion. In anesthetized rats, i.v. PGE2 inhibited hormone-stimulated protein secretion but did not change fluid and bicarbonate output, while i.v. enprostil inhibited cholecystokinin-stimulated fluid, bicarbonate, and protein output in the pancreatic juice.(ABSTRACT TRUNCATED AT 250 WORDS)

Central and peripheral effects of prostaglandin E2 and enprostil on gastric acid secretion in the rat.

The intracerebroventricular (i.c.v.) administration of prostaglandin E2 (PGE2) inhibits gastric secretion at doses that are inactive by i.v. administration in the rat. The present study was undertaken to examine the central and peripheral effects of enprostil, a potent synthetic PGE2 analogue, on gastric acid secretion as compared to those of PGE2. We used conscious rats equipped with a chronic gastric fistula and a cannula to allow injection into the third ventricle of the brain. Gastric acid output was measured under basal interdigestive conditions and during stimulation with submaximal doses of pentagastrin and histamine. Total inhibition of basal and stimulated gastric acid output was obtained after i.c.v. PGE2 and after i.c.v. or i.v. enprostil administration. After i.v. PGE2, the maximal observed inhibition was not greater than 50%. The ratio of ED50 values for i.v. administered to i.c.v. administered PGE2 was 64 or more, whereas the ratio of ED50 values for i.v. enprostil to i.c.v. enprostil was 9 to 13. Under all conditions studied, enprostil was more potent than PGE2 and this greater potency was more prominent after i.v. administration (ratio 250 to 2500) than after i.c.v. administration (ratio 10 to 400). The blockade of alpha 2-adrenoceptors by idazoxan did not suppress the inhibition of gastric secretion produced by i.c.v. PGE2 or enprostil. It is concluded that low doses of PGE2 inhibit gastric acid output mainly through a central mechanism, whereas low doses of enprostil potently inhibit gastric acid output through both a central and a peripheral mechanism. alpha 2-Adrenoceptors are not essential for the effect of i.c.v. prostanoids on gastric acid secretion.

[Giant leiomyoma of the esophagus detected by echocardiography and corroborated by x-ray computed tomography and surgery]. / Léiomyome géant de l'oesophage détecté par échocardiographie et confirmé par tomodensitométrie et chirurgie.

The authors report the case of a 44 year old man with a giant leiomyoma of the lower third of the esophagus. The patient presented with chest pain and the tumour was detected by echocardiography. The diagnosis was confirmed by computerised tomography and histological examination of the surgical specimen weighing 501.5 g. The surgeon performed a large esophago-gastric resection and reestablished the continuity of the digestive track by interposing a section of colon. A good result was obtained with a follow-up of 4 years. The authors underline the potential value of a simple barium swallow during cardiological assessment.

[Glaphenine biliary lithiasis. Identification by infrared spectrophotometry]. / Lithiase biliaire de glafénine. Identification par spectrophotométrie infrarouge.

The authors report the case of a woman, presenting with choledocholithiasis essentially composed of glafenic acid. Identification of the drug and its metabolites was demonstrated using infrared spectrophotometry and thin layer chromatography. To our knowledge, this is the first publication of drug choledocholithiasis.

[A case of digestive epilepsy with late diagnosis: a disease not to be disregarded]. / Un cas d"épilespie digestive de diagnostic tardif: une pathologie à ne pas méconnaître.

Digestive epilepsy is a rare disease, poorly recognized by gastroenterologists. Its diagnosis requires a compatible clinical presentation, the absence of concomitant organic digestive disease, and an effective and long-lasting response to specific anticonvulsant agents. We report a case of digestive epilepsy due to a meningioma of the right parietal lobe in a 79-year-old woman suffering from headaches, vertigo, sweating and abdominal pain for at least 14 years. Initial diagnosis was irritable bowel syndrome. A meningal syndrome led to neurological work-up showing cerebral meningioma. The recurrent paroxysmal abdominal pain was interpreted as manifestations of digestive epilepsy, and effective and long-lasting treatment was obtained with carbamazepine. After analysis of the determining elements in this case, the epidemiology, pathophysiology, diagnostic work-up, therapy, and differential diagnosis of digestive epilepsy are discussed.

[Hepatic involvement in secondary syphilis]. / Atteinte hépatique au cours de la syphilis secondaire.

A case of secondary syphilitic hepatitis is reported. A 49-year old woman was admitted for weight-loss, fever, hepatomegaly and splenomegaly. Diagnosis of syphilitic hepatitis was based on cholestasis associated with positive serologic tests for syphilis without other immunological disturbances. Biopsy of the liver showed a moderate infiltration in and around the portal tracts. Immunofluorescence study for treponema was negative. Rapid improvement was obtained with penicillin initially associated with steroid therapy. Liver involvement in secondary syphilis is characterized by anicteric cholestasis, an inflammatory syndrome, and periportal infiltrate inconstantly associated with centrilobular necrosis, granulomatous reaction and presence of treponemas in the lesions. Due to the increasing frequency of sexually transmitted diseases, this diagnosis could become more frequent.

[Use of a medium and long chain triglyceride mixture for parenteral nutrition in a university hospital: results of an internal audit]. / Utilisation d'un mélange de triglycérides à chaînes longues et chaînes moyennes pour la nutrition parentérale en hôpital universitaire. Résultats d'un audit interne.

OBJECTIVES: The aim of this study was to determine whether a medium and long chain triglyceride mixture for parenteral nutrition is used in accordance with indications and contraindications in hospital practice. METHODS: Patient data recorded in 30 consecutive patients included illness, nutritional status, laboratory findings before nutrition as well as indications and contraindications for parenteral nutrition. RESULTS: When expressed in g.kg-1.day-1 maximal recommended doses of the mixture were exceeded in 32% but there was no excess when expressed in g.kg-1.hr-1. Serious hepatic insufficiency was present in 11% of the patients, 38% had hypertriglyceridemia and one had serious coagulopathy. There were 3 contraindications for the mixture. CONCLUSION: Indications for using this emulsion were respected, but there were contraindications in 45% of the cases. These contraindications are however questionable as is the daily dosage. Because the mixture seems better for use in many cases of parenteral nutrition, it would appear best to discuss the prescription case by case.

[Report of a case of post-radiation hepatopathy]. / A propos d'un cas d'hépatopathie post-radique.

We report the case of a 65 year-old woman treated by radiation therapy alone for Hodgkin's disease. She developed febricule, nonicteric cholestasis, and inflammatory syndrome two months after irradiation. The clinical record, biological and histological results allowed us to dismiss another etiology especially an hepatic location of Hodgkin's disease. Out come after a twenty months predominance of pathohistological abnormalities in the centrilobular region were in favor of a radiation-induced hepatitis.

[Cancer of the extrahepatic biliary tracts and abnormality of the biliopancreatic junction]. / Cancer des voies biliaires extra-hépatiques et anomalie de la jonction bilio-pancréatique.

This retrospective study was undertaken to evaluate the incidence of an abnormal pancreaticobiliary ductal union (long common duct) in biliary tract carcinoma. Of 86 patients presenting with such a cancer, 67 had a pre- or intra-operative radiologic examination. An abnormal pancreaticobiliary ductal union was found in only one 60 year old woman having stones associated with invasive gallbladder carcinoma. Operative cholangiogram revealed an early and marked Wirsung opacification with a 1.5 cm long common duct. This low incidence in our study contrasts deeply with Japanese data and raises several questions about the correct evaluation of pancreaticobiliary ductal union, the true consequences of such an anomaly and possible interracial variations in incidence.

[Diaphragm of inferior vena cava associated with Budd-Chiari syndrome. Contribution of ultrasonography and color Doppler echocardiography]. / Diaphragme de la veine cave inférieure associé à un syndrome de Budd-Chiari. Apport de l'échographie et du Doppler couleur.

We report the case of a young man presenting clinical features of portal hypertension of unknown origin. The ultrasonographic examination showed suprahepatic blockage signs leading to the diagnosis of Budd-Chiari syndrome caused by incomplete diaphragm of the inferior vena cava. The color Doppler examination suggested caval obstruction, showing an abrupt shift from a laminar to a bosterous flux. Secondly cavograms and surgery later confirmed the diagnosis.

[Ultrasonographic aspect of the rectal wall in liver cirrhosis]. / Aspect échographique de la paroi rectale au cours de la cirrhose.

The aim of this study was to assess the ultrasonographic abnormalities of the rectal wall and surrounding structures in patients with cirrhosis and to correlate these findings with endoscopy. From November 1992 to May 1993, 53 cirrhotic patients and 30 control subjects were examined by transrectal ultrasonography and rectoscopy. In addition to rectoscopy and transrectal ultrasonography, patients with cirrhosis underwent an upper gastrointestinal endoscopy. Ultrasonography abnormalities of the rectum were detected in 32 cases of cirrhosis (60.5%): a) in 21 cases the rectal wall thickness was greater than 5 mm and the sub-mucosa was thickened ( > or = 2 mm) and dissected by thin echo-free elements; b) the remaining 11 patients presented, in addition to the previously described abnormalities, rounded elongated echo-free structures surrounding the rectum which were not found in the control group. All these 11 patients had rectal varices at rectoscopy. In the group of cirrhotic patients, rectoscopy showed abnormal dilated veins in 23 cases (43.5%) and rectal varices in 11 cases. Ultrasonographic and endoscopic abnormalities of the rectum were more often visualized in the group of cirrhotic patients than in the control group (P < 0.001). In patients with cirrhosis, the demonstration of rectal varices was associated with transrectal ultrasound abnormalities (P < 0.01), and in particular peri-rectal vascular formations. In cases of cirrhosis the rectal wall abnormalities were not associated with gastric varices at endoscopic inspection but were linked with large esophageal varices or gastric mucosal abnormalities demonstrated on endoscopy (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Alithiasic cholecystitis and viral hepatitis B disclosing periarteritis nodosa]. / Cholécystite alithiasique et hépatite viral B révélatrices d'une périartérite noueuse.

The authors report the case of a patient with acute alithiasic cholecystitis associated with viral B hepatitis revealing periarteritis nodosa. Histopathological results showed signs of focal arteritis in the gallbladder and liver. Because of the negativity of the viral DNA in serum and the lack of histopathological necrosis in hepatic specimen, the patient was treated by steroid therapy only with a rapid regression of signs of vasculitis and the disappearance of the hepatitis markers.

[Developmental adrenal tuberculosis. Value of x-ray computed tomography]. / Tuberculose surrénalienne évolutive. Intérêt de la tomodensitométrie.

Two cases of Addison's disease secondary to active adrenal tuberculosis are reported. Computed tomography showed hypertrophy of the adrenal gland, which was bilateral in one case and unilateral in the other. Repeat computed tomography scans during antituberculous chemotherapy demonstrated a progressive change of the adrenals toward atrophy and calcification, while the adrenal function remained impaired. The authors recall that adrenal tuberculosis may be unilateral first, then bilateral, and that the gland is initially hypertrophic before hormonal deficiency appears; later on, adrenal atrophy and calcification develop. Computed tomography seems to be useful in the aetiological diagnosis of Addison's disease. Moreover, it helps in determining whether or not antituberculous therapy is indicated, which is not always easy to decide in the absence of "active" focus. The finding, with or without positive tuberculin skin tests, of an adrenal hypertrophy unexplainable by any other pathology (e.g. metastasis, histoplasmosis) should call for antituberculous treatment, especially since it sometimes results in recovery of adrenal function.

[Digestive surgery in patients over 80 years of age. Apropos of 690 operations]. / La chirurgie digestive chez les sujets de plus de 80 ans. A propos de 690 interventions.

Between January 1981 and December 1990, 690 patients over the age of 80 years underwent gastrointestinal surgery. These operations were performed for diseases of the biliary tract in 248 cases (28%), colon or rectum in 238 cases (27%), stomach or duodenum in 130 cases (15%), small bowel in 32 cases (1.6%), oesophagus in 16 cases (1.8%), and for peritoneal carcinologic dissemination in 26 cases (3%). Emergency operation was performed in 43% of patients. Surgery was considered to be curative in 61% of patients. Overall postoperative mortality was 23%. The six following factors were associated with increased mortality: age over 85 years, ASA categories 3, 4, 5; surgery for malignant disease, peritonitis, palliative surgery, emergency surgery.

[Acute recurrent pancreatitis and heterozygous mutation of the cystic fibrosis gene: a case report]. / Pancréatite aiguë récidivante et mutation hétérozygote du gène CFTR. A propos d'un cas.

UNLABELLED: Recurrent pancreatitis is seldom associated with CFTR (Cystic Fibrosis Transmembrane Regulator) gene mutation. CASE REPORT: A 17-year-old boy presented with isolated idiopathic pancreatitis. CFTR gene mutations study revealed delta F508 heterozygous mutation. CONCLUSION: Mutations for the CFTR gene should be explored in case of recurrent pancreatitis.

[Non-cirrhotic ascites: pathophysiology, diagnosis and etiology]. / L'ascite non liée à la cirrhose : physiopathologie, diagnostic et étiologies.

Ascites, in 20% of cases, is not linked to liver cirrhosis. The pathophysiology is most often different. The understanding of these pathophysiological mechanisms can lead to etiologic diagnosis. The diagnostic approach is mainly based on the biological study of ascites, especially protein concentration and albumin gradient between serum and ascites. In Western countries, tumors and heart diseases are the predominant causes, while developing countries are mainly concerned by infectious diseases, among which tuberculosis is the leading cause. Other uncommon causes must be recognized, as ascites may be the presenting feature of the disease. Their knowledge will facilitate the therapeutic approach.