Associations between EBV serostatus and organ transplant type in PTLD risk: an analysis of the SRTR National Registry Data in the United States.

In a prior multiorgan transplant database study, recipient Epstein-Barr virus (EBV) seronegativity was not associated with increased risk for posttransplant lymphoproliferative disorders (PTLD) in liver transplants (LTX), at variance with prior single center reports and with data from kidney and heart transplants (KTX and HTX). The Scientific Registry of Transplant Recipients (SRTR) in the United States is the only other registry with data on the required variables for comparison.Our study set comprised 112 756 KTX (580 PTLDs; 0.51%), 13 937 HTX (140 PTLDs; 1.0%) and 40 437 LTX (383 PTLDs; 0.95%) performed January 2003 onward. The unadjusted hazard ratio (HR) for PTLD if recipient EBV seronegative was 5.005 for KTX, 6.528 for HTX and 2.615 for LTX (p < 0.001 for all). In models adjusted for multiple covariates, the adjusted HR was 3.583 (p < 0.001) for KTX, 4.037 (p < 0.001) for HTX, 1.479 (p = 0.03) for LTX. Interaction models using EBV seropositive KTX as reference group showed significantly higher risk for all other EBV seronegative organ transplant groups and also for EBV seropositive LTX (AHR 2.053, p < 0.0001).Recipient EBV seronegativity is still significantly associated with risk for PTLD in LTX, though less so because of higher baseline risk in the EBV seropositive LTX group.

Demonstration and immunochemical characterization of carcinoembryonic antigen in human pancreatic juice.

Pancreatic juice collected from 10 patients without evidence of malignant disease of the pancreas or other organs was pooled, extracted, and fractionated by Sepharose 6-B and Sephadex G-200 gel filtration. The carcinoembryonic antigen (CEA) activity in the material was demonstrated and studied by: a) radioimmunoassay, b) competitive binding to antibodies against CEA, c) precipitin inhibition, and d) Ouchterlony analysis. The immunochemical identity of the active material to CEA purified from liver metastases of colon cancer was demonstrated.

Pancreas divisum: its association with pancreatitis.

Thirty-three patients with pancreas divisum studied by endoscopic retrograde cholangiopancreatography (ERCP) are described. Documented pancreatitis was present in fifteen patients, and another eleven had recurrent episodes of pain typical of pancreatitis. The major papilla was cannulated in all patients, but the duct of Wirsung was opacified in only twenty-eight and showed changes of pancreatitis in one. Attempts were made to cannulate the minor papilla in fifteen of the thirty-three patients and were successful in four. The duct of Santorini showed typical changes of pancreatitis in one. One patient had pancreatic cancer, and the duct of Wirsung demonstrated only nonspecific abnormalities. In only two cases was pancreatitis due to alcohol abuse. The high incidence of pancreatitis and pancreatic-like pain in patients with pancreas divisum, may be due to the very small ampulla of the duct of Santorini which in these patients drains the majority of the pancreas, creating a marked relative stenosis of the ampulla. Surgery for relief of pain was required in five patients. The operation of choice, when pancreatitis involves the dorsal pancreas, appears to be distal resection with drainage.

Secretion of beta-lactam antibiotics in pure human pancreatic juice.

The secretion of cephalothin and cefoxitin in stimulated pure pancreatic juice was studied in 13 persons after intravenous administration of antibiotics. Of all these studied, three had acute relapsing pancreatitis, five chronic pancreatitis, and five were control subjects. Antibiotic levels were measured in paired pure pancreatic juice and serum samples at fixed time intervals after administration. Cephalothin was detected in very low levels (1 to 1.8 micrograms/ml) in the pure pancreatic juice of four of the six persons studied (3 micrograms/ml). Although therapeutic levels were not obtained in stimulated pure pancreatic juice with either antibiotic, additional studies evaluating antibiotic levels in unstimulated pure pancreatic juice and in pancreatic tissue would be helpful in assessing the role of antibiotic therapy in the treatment of pancreatitis.

Endoscopic retrograde cholangiopancreatography and gray-scale abdominal ultrasound in the diagnosis of jaundice.

Fifty-five patients with suspected obstructive jaundice were studied with both ERCP and abdominal ultrasound. Biliary tract obstruction was documented in 49 patients and parenchymal liver disease in 7. A definite cause of jaundice was demonstrated by ERCP in 45 of 49 patients with biliary tract obstruction but in only 28 of 49 patients by ultrasound. Bile duct dilatation, where present, was detected by ERCP in only 33 of 42 patients. ERCP was particularly effective in patients with common duct stones; common duct calculi and a dilated common duct were detected in 15 of 16 such patients. Dilated bile ducts where present were detected by ultrasound in 22 of 42 patients. Ultrasound was particularly helpful in patients with pancreatic cancer in whom a dilated common duct could not be opacified during ERCP. ERCP and abdominal ultrasound together provide a rapid and safe method of diagnosis in the jaundiced patient with suspected bile duct obstruction.

Endoscopic measurement of pancreatic juice secretory flow rates and pancreatic secretory pressures after secretin administration in human controls and in patients with acute relapsing pancreatitis, chronic pancreatitis, and pancreatic cancer.

Secretory flow rates were measured inside the main pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute relapsing pancreatitis, chronic pancreatitis, and pancreatic cancer and in controls after intravenous administration of secretin. Peak secretory flow rates in these groups were 5.04 +/- 1.74, 0.71 +/-1.28, 0.60 +/- 1.37, and 4.13 +/- 0.88 ml/min, respectively. Peak secretory pressures were also measured intraductally in patients with acute relapsing pancreatitis and pancreatic cancer and in controls and were 402 +/- 69, 75 +/- 161, and 403 +/- 99 mm pancreatic juice, respectively. Peak secretory flow rates and pressures measured in controls during constant administration of secretin were similar to those measured when secretin was administered as a bolus.

Rhythm abnormalities of the biliary and pancreatic sphincters: diagnosis by endoscopic manometry.

Abnormal phasic wave activity was noted in the biliary duct sphincter, pancreatic duct sphincter, or both in 43 patients. This abnormality consisted of a tachyrhythmia in 40 patients and absent phasic wave activity in 3 patients. Tachyrhythmia was encountered in patients with elevated basal sphincter pressures. In four patients with tachyrhythmia, administration of intravenous naloxone failed to modify phasic wave activity. Three patients with normal basal sphincter pressures had absent phasic wave activity. This abnormality occurred in two patients with cirrhosis and in one patient with suspected cirrhosis. In one patient with cirrhosis, administration of intravenous morphine did not induce phasic wave activity.

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.

Pancreas divisum. Results of surgical intervention.

The embryologic defect that results when the ventral and dorsal anlages of the pancreas do not fuse has been referred to as pancreas divisum. ERCP has made it possible to recognize this anomaly in patients undergoing investigation for otherwise unexplained abdominal pain. Of 70 patients in whom recurrent epigastric pain and pancreas divisum coexisted, sphincteroplasty of both papillae was carried out in 19 because of intractability of symptoms. In six patients, surgery was performed subsequent to failure of other biliary tract surgery. There was one postoperative death. In the remaining 18 patients, initial results were good to excellent in 13 and fair in 1. In four patients, however, recurrence of symptoms developed within periods that ranged from 1 to 6 months; therefore, reasonably permanent relief was limited to 10 patients. Of the remaining eight patients with recurrent or continuing symptoms, a variety of subsequent procedures led to satisfactory results in only three. In only seven patients was there even minimal chemical or microscopic evidence to suggest active pancreatitis. Similarly, pancreatograms in 17 patients with this anomaly revealed no abnormalities except for minor ones in 2 patients. Thus, if this is a syndrome that is due to relative stenosis of the lesser papilla and duct, the anomaly does not often result in documented pancreatitis. The definite but limited success rate from sphincteroplasty suggests that relative stenosis of the lesser papilla may be the cause of a syndrome but surgical refinements will be necessary to achieve a better operative success rate.

Importance of common bile duct stricture associated with chronic pancreatitis. Diagnosis by endoscopic retrograde cholangiopancreatography.

Twenty-one patients with common bile duct strictures associated with chronic pancreatitis are described in whom ERCP was the principal diagnostic method used. In 5 of the 11 patients who had had previous pancreatic or biliary surgery, a common bile duct stricture was overlooked. Nine patients had one or more attacks of cholangitis which were severe in seven and caused death in one. Endoscopically aspirated bile cultures showed heavy gram-negative infection in four patients with previous cholangitis. Two patients developed stones above the strictures, and in one this led to obstruction of a previous cholecystjejunostomy. Although strictures may be discovered at an asymptomatic stage, there should be careful follow-up to detect the appearance of any symptoms or objective signs of stricture progression, when surgery should be offered without delay. Direct biliary-enteric anastomosis is the procedure of choice when possible to relieve symptoms and prevent the potentially life-threatening complications of cholangitis and septicemia.

Postcholecystectomy syndrome and its association with ampullary stenosis.

Fifty-six consecutive patients returning with recurrent or persistent upper abdominal pain after cholecystectomy were studied by endoscopic retrograde cholangiopancreatography, abdominal ultrasound and morphine neostigmine test. In 44 patients, pain recurred within 6 months after cholecystectomy. Forty patients were demonstrated on endoscopic retrograde cholangiopancreatography to have moderate to marked ampullary stenosis, which occurred as an isolated abnormality in 32 patients and in association with pancreatitis in 8. Thirteen patients were found to have pancreatitis, and 6 had retained common duct stones. In five patients no definite abnormality was demonstrated. The morphine neostigmine test was positive in 16 of 17 patients with isolated ampullary stenosis and in only 1 of 8 with pancreatitis. This test may be helpful in patients who are to undergo cholecystectomy. In those with positive results, endoscopic retrograde cholangiopancreatography would help assess the size of the ampullary sphincter so that sphincteroplasty could be done at the time of cholecystectomy in appropriate patients.

Duodenoscopy and endoscopic pancreatography in patients with postive morphine prostigmine tests.

Twenty-three patients with abdominal pain and positive morphine prostigmine tests underwent duodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP). Sixteen demonstrated marked or moderate ampullary stenosis. The pancreatic duct was dilated in three and stenotic in four. Ampullary stenosis was confirmed in all patients who subsequently underwent sphincteroplasty. Only six patients had pancreatitis demonstrated by appropriate laboratory studies or at surgery. Relief of pain after sphincteroplasty was complete in ten patients during follow-up.