Role of radial endosonography in the diagnosis of acute cholangitis.

BACKGROUND AND STUDY AIM: We aimed to assess radial endoscopic ultrasound (EUS) features of the bile duct wall as well as biliary luminal liquid characteristics in cases with acute cholangitis. PATIENTS AND METHODS: This prospective study was performed during the period from January 2009 to February 2010 in a tertiary referral center. Twenty-eight patients with acute cholangitis and 60 patients without acute cholangitis but with cholestasis due to gallstone disease were enrolled in the study. During radial EUS examination, sonographic features of the common bile duct wall, the intraductal luminal content, and nearby periductal structures were investigated. Mild hyperechogenic-heterogenic appearances with waving-type movements without acoustic shadowing enclosing one-third of the common bile duct were noted as purulent materials. RESULTS: EUS indicated an increased focal and/or diffuse concentric bile duct wall thickness (>1.5 mm) in 68 and 27% of the cases with and without acute cholangitis, respectively. The mean bile duct wall thickness was 1.9 mm (0.9-2.9 mm) and 1.1 mm (0.6-2.1 mm) in the study and control groups, respectively (P < 0.05). On EUS, a pericholedochal hypoechoic strand more than 1.5 cm in length was present in 13 of 28 patients with acute cholangitis (46%). It was less than 1 cm long in 11 cases without acute cholangitis (18%). Bile duct content with heterogenous dense echogenicity without acoustic shadowing was present in 18 patients (64%) with acute cholangitis and in two patients (3%) without cholangitis. Those 20 patients were successfully drained with a same-day endoscopic retrograde cholangiography (ERCP) procedure which confirmed purulent biliary content after sphincterotomy. Same-day ERCP revealed no purulent material drainage from the bile duct in the other eight patients without cholangitis. The accuracy and positive and negative predictivity of diffuse concentric wall thickening and a peribiliary hypoechoic strand of greater than 1.5 cm in length for a diagnosis of acute cholangitis were 91, 86.3, and 67.1%, and 76, 72, and 54%, respectively. For purulent material, the accuracy and positive and negative predictive values of EUS for acute cholangitis were noted to be 87, 93.3, and 82%, respectively. CONCLUSION: Through this study, it was concluded that EUS findings such as diffuse and/or concentric wall thickening of more than 1.5 mm and intraductal heterogenous echogenicity without acoustic shadowing are highly accurate and predictive for diagnosing acute cholangitis.

Technetium-99m hexamethyl propylene amine oxime-labeled leukocyte scintigraphy at three different times in active ulcerative colitis: comparison with colonoscopy and clinico-biochemical parameters in the assessment of disease extension and severity.

OBJECTIVE: In this study, our objective was to define the usefulness of technetium-99m hexamethyl propylene amine oxime (Tc-99m HMPAO)-labeled leukocyte scintigraphy at three different time points in the assessment of disease extension and severity in patients with active ulcerative colitis (UC). METHODS: Twenty-one consecutive patients (10 women, 11 men; mean age 42.4 +/- 12 years) with active UC were prospectively studied. All patients were diagnosed by colonoscopy and histopathology prior to inclusion. Scintigraphy was performed at 1 h, 2 h, and 4 h after Tc-99m HMPAO-labeled leukocyte injection. Clinic-biochemical activity score, total colonoscopic activity score, and total scintigraphic activity score at 1 h, 2 h, and 4 h were calculated for each patient. RESULTS: Sensitivity, specificity, and accuracy values of Tc-99m HMPAO-labeled leukocyte scintigraphy were calculated as follows, respectively: 1 h imaging 86%, 73%, and 83%; 2 h imaging 89%, 74%, and 86%; 4 h imaging 90%, 58%, and 83% in the detection of active inflammatory segments. Even though no statistically significant difference was found between 1 h, 2 h, and 4 h imaging with respect to the sensitivity, specificity of labeled leukocyte scintigraphy, the largest area under the curve value was found for 2 h imaging. CONCLUSIONS: Tc-99m HMPAO-labeled leukocyte scintigraphy has been found to be correlated well with colonoscopy in the assessment of both the extension and severity of UC. We recommend 2 h scintigraphic imaging because it provides the largest area under the curve value and decreases the number of false-positive results.

The epidemiology of acute respiratory failure in critically ill patients(*).

STUDY OBJECTIVES: To describe the risk factors for the development of and mortality resulting from acute respiratory failure (ARF) in a large patient population. DESIGN: A substudy of a prospective, multicenter, observational cohort study, which was designed to validate the sequential organ failure assessment score. SETTING: Forty ICUs in 16 countries. PATIENTS: All critically ill patients who were admitted to one of the participating ICUs during a 1-month period were observed until the end of their hospital course. MEASUREMENTS AND RESULTS: Of the 1,449 patients who were enrolled into the study, 458 (32%) were admitted to an ICU with ARF, as defined by a PaO(2)/fraction of inspired oxygen ratio of < 200 mm Hg and the need for respiratory support. Patients who presented with ARF were older than the other patients (63 vs 57 years, respectively; p < 0.001) and more commonly had an infection (47% vs 20%, respectively; p < 0.001). The length of ICU stay was longer (6 vs 4 days, respectively; p < 0.001) and the ICU mortality rate was more than double (34% vs 16%, respectively; p < 0.001) in ARF patients compared to non-ARF patients. Of the 991 patients who were admitted to an ICU without ARF, 352 (35%) developed ARF later during the ICU stay. The independent risk factors for the development of ARF were infection developing in the ICU (odds ratio [OR], 7.59; 95% confidence interval [CI], 5.08 to 11.33) or present on ICU admission (OR, 2.3; 95% CI, 1.68 to 3.16), the presence of neurologic failure on ICU admission (OR, 2.73; 95% CI, 1.90 to 3.91), and older age (OR, 1.70; 95% CI, 1.30 to 2.22). Of all 810 patients with ARF, 253 (31%) died. The independent risk factors for death were multiple organ failure following ICU admission, history of hematologic malignancy, chronic renal failure or liver cirrhosis, the presence of circulatory shock on ICU admission, the presence of infection, and older age. CONCLUSIONS: The present study stresses that ARF is common in the ICU (56% of all patients) and that a number of extrapulmonary factors are related to the risk of development of ARF and to mortality rate in these patients.

Hepatic epithelioid hemangioendothelioma treated with orthotopic liver transplantation: a case report.

Hepatic epithelioid hemangiendothelioma is a rare vascular tumor. The clinical course is unpredictable and different treatment modalities are offered depending on the patients condition. Orthotopic liver tranplantation is the choice of treatment in diffuse cases without metastases. A 32 year old woman was admitted to hospital with multiple mass lesions diagnosed by ultrasonography of the liver. Physical examination was normal except for a painless hepatomegaly, and her biochemical tests were within the normal range. Computed tomographic scanning showed the presence of multiple lesions in both lobes, some of which were accompanied by a small degree of calcification. Although these findings were suggestive of hepatic epithelioid hemangioendothelioma, ultrasonographic guided fine needle aspiration biopsy failed to diagnose the exact nature of the lesions. The diagnosis of hepatic epithelioid hemangioendothelioma was confirmed by diagnostic laparotomy and immunohistochemical examination of the specimen by FVIII-RAg, CD34 and CD 31 markers. The patient was treated by orthotopic liver transplantation and had no evidence of tumor 18 months after transplantation. The problems in differential diagnosis and treatment options are discussed in this report of the first case of this rare tumor, treated by orthotopic liver transplantation in Turkey.

The efficacy of endoscopic ultrasonography in local staging of rectal tumors.

BACKGROUND/AIMS: The purpose of this study was to research the efficacy and reliability of endoscopic rectal ultrasonography in local staging (T and N stages) of rectal tumors. MATERIALS AND METHODS: This retrospective study was carried out by the Department of Gastroenterology, Izmir Atatürk Training and Research Hospital, which is tertiary level. Thirty-one patients with adenocarcinoma were included in the study. The patients found operable according to computed tomography underwent preoperative local staging by endoscopic ultrasonography. Radial endoscopic ultrasonography and T and N stages were evaluated. RESULTS: It was observed that endoscopic rectal ultrasonography had 80.6% accuracy, 93.4% sensitivity, and 96.5% specificity in T stage; 70% accuracy, 70% sensitivity, and 86% specificity in the detection of presence of lymph node; and 76% accuracy, 100% sensitivity, and 22% specificity in the detection of the nature of lymph node. CONCLUSIONS: In this study, it was observed that endoscopic rectal ultrasonography is an efficient and reliable method in the detection of local lymph node and the depth of invasion of rectal tumors (T staging), although it is not reliable enough to determine the characteristics of lymph nodes.

Does presence of common bile duct stones in patients with acute biliary pancreatitis affect the severity of illness or laboratory findings?

BACKGROUND/AIMS: To determine the effect of stone within the common bile duct, on the severity of acute biliary pancreatitis. MATERIAL AND METHODS: This is a prospective and cross sectional study which was conducted at a tertiary care hospital including 103 patients. Serum biochemical values and white blood cell counts at the first 12th and 72nd hours of presentation were evaluated. The patients were grouped according to the presence or absence of common bile duct stones which were diagnosed by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. Besides, the patients were classified as mild and severe acute pancreatitis according to the data provided by computed tomography (Balthazar scoring) and clinical assessment and blood samples. RESULTS: Among the 103 patients with acute biliary patients, radial endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography revealed stones and/or sludge within the common bile duct or ampulla in 41 (39.8%) patients. There was not any persistent common bile duct stone in 62 (60.2%) patients. Severe pancreatitis developed in 9 (22%) of 41 patients who were determined to have stones by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography, and in 13 (21%) of 62 patients who were not. There was no difference in the incidence of progressing to severe acute biliary patients between patients with and without common bile duct stones (p=0.45). CONCLUSION: Presence of common bile duct stones do not correlate with the severity of acute biliary pancreatitis.

Time course of platelet counts in critically ill patients.

BACKGROUND: Although thrombocytopenia in the intensive care unit (ICU) is associated with a poorer outcome, the precise relationship between the time course of platelet counts and the mortality rate has not been well defined. OBJECTIVE: To describe the time course of the platelet count in relation to the mortality rate in critically ill patients. DESIGN: Substudy of a prospective, multicenter, observational cohort analysis. SETTING: Forty ICUs in 16 countries from Europe, America, and Australia. PATIENTS: Data were collected from all ICU admissions in a 1-month period, excluding patients younger than 12 yrs old and those who stayed in the ICU for <48 hrs after uncomplicated surgery. A total of 1,449 critically ill patients were enrolled, including 257 who stayed in the ICU for >2 wks. INTERVENTIONS: None. MEASUREMENTS: Platelet counts were collected daily throughout the ICU stay, together with other measures of organ dysfunction. Thrombocytopenia was defined as a platelet count of <150 x 103/mm3. A relative increase in platelet count was defined as a 25% increase above the admission value, together with an absolute platelet count of > or =150 x 103/mm3. MAIN RESULTS: For the entire population, the platelet count was lower in the 313 nonsurvivors than in the 1,131 survivors throughout the ICU course. Of the 257 patients who stayed in the ICU for >2 wks, 187 (64%) survived. The platelet count decreased significantly in the first days after admission to reach a nadir on day 4 in both survivors and nonsurvivors. In the survivors, the platelet count returned to the admission value by the end of the first week and continued to rise to become significantly greater than the admission value by day 9. In the nonsurvivors, the platelet count also returned to the admission value after 1 wk, but there was no subsequent increase in platelet count. A total of 138 (54%) patients had thrombocytopenia on day 4, and these patients had a greater mortality rate than the other patients (33% vs. 16%; p <.05). On day 14, 51 (20%) patients had thrombocytopenia, and these patients had a greater mortality rate than the other patients (66% vs. 16%; p <.05). Thrombocytopenia was less common on day 14 than on day 4 (20% vs. 54%; p <.05), but the mortality rate was greater in the thrombocytopenic patients on day 14 than those who were thrombocytopenic on day 4 (66% vs. 33%; p <.05). The ICU mortality rate of nonthrombocytopenic patients on day 14 was also significantly lower in patients with, than without, a relative increase in platelet count on day 14 (11% vs. 30%; p <.05). CONCLUSION: Platelet count changes in the critically ill have a biphasic pattern that is different in survivors and nonsurvivors. Late thrombocytopenia is more predictive of death than early thrombocytopenia. A relative increase in platelet count after thrombocytopenia was present in survivors but not in nonsurvivors. Although a single measured platelet count is of little value for predicting outcome, changes in platelet count over time are related to patient outcome.