Day Bed Unit at the Department of Gastro-enterology. Experience of a study group.

Day Bed Unit at the Department of Gastroenterology. Experience of a study group. We analyzed the activity of the Day-Bed Unit at the Department of Gastroenterology of Turin Hospital (Molinette). The quality of the service provided and the days of stay in hospital for each admission were evaluated in terms of cost benefit ratio. The average stay in hospital for each admission was 2.57 days as opposed to 9.3 in the in patient ward. Patients were divided in subsets according to the cause of admission. Stratifying the patients according to diagnosis showed a hospital stay of 2.73 days for liver disease and of 2.81 for pancreas and biliary disease. Among the admissions for liver disease, pre or posttranspiant patients required 2.89 days as opposed to 2.62 days of those who were treated for esophageal varices. Thus, the cause of admission was a factor influencing length of hospital stay. Patients needing non surgical treatment for liver cancer took 2.22 days if treated with percutaneous ethanol injection; those undergoing chemoembolization required 2.93 days. In conclusion, the day bed unit has proven to be able to provide a service with a good cost benefit ratio. Patients admitted to this service may be withdrawn from the waiting list of the in patient ward, thus reducing the waiting time. Optimization of this service needs integration with the surroudings Units within the Department and in the Hospital.

[Groove pancreatitis. A case report of chronic focal pancreatitis]. / La "groove pancreatitis". Descrizione di un caso di pancreatite cronica focale.

The "groove pancreatitis" is a special form of segmental chronic pancreatitis affecting the "groove" between pancreatic head, duodenum and common bile duct. This type of chronic pancreatitis was first described in 1973 and only few cases have been reported in literature. Unlike other forms of chronic pancreatitis, this is often preceded by peptic ulcers, gastric resections or biliary tract diseases; it could be associated with cysts of the duodenal wall and pancreatic cysts. Abdominal pain, vomiting due to duodenal stenosis, obstructive jaundice and weight loss are the most common presenting symptoms. The radiological features show a pancreatic mass similar to a pancreatic head carcinoma and the discrimination of groove pancreatitis from pancreatic carcinoma is often difficult or even impossible in some patients. We describe a case of groove pancreatitis treated with pancreatoduodenectomy, reviewing the clinical and radiological features. We remark that the groove pancreatitis is a disease that must be known and should be considered in the differential diagnosis of pancreatic carcinoma.

Minute and small early gastric cancers in a Western population: a clinicopathologic study.

Early endoscopic diagnosis improves the prognosis of patients with gastric cancer, as shown by the finding that 5-year survival rates exceeding 90% are observed in Japanese patients with early gastric cancer. It has been hypothesized that tumor size may have prognostic significance; therefore, a distinction between minute, small, and large early gastric cancers has been proposed. The aim of this study was to determine the prevalence of minute and small early gastric cancers in Western countries and to compare their clinicopathologic features with those of large early gastric cancers. Of 465 Italian patients with gastric cancer who were studied, 20.5% had an early gastric cancer, and 34.7% of these were minute or small. Tumor size is correlated with intramural spreading and metastasis to perigastric lymph nodes. Nodal involvement occurs more frequently in the diffuse than in the intestinal type of early gastric cancer. Long-term survival rate is not correlated with tumor size, intramural spreading, or nodal metastasis. The minute and small early gastric cancers of Italian patients are indistinguishable from those occurring in Japanese patients. These lesions are more common than previously thought and should be carefully searched for by endoscopists. The correlation of tumor size with intramural invasion and perigastric lymph node metastasis suggests that minute and small early gastric cancers are precursors of large early gastric cancers. Although the distinction between minute, small, and large early gastric cancers is of low prognostic value, the distinction might be useful for selecting different therapeutic approaches.

Fistulosphincterotomy in the endoscopic approach to biliary tract diseases.

We report our experience with 49 patients who underwent fistulosphincterotomy (FS) after cannulation of the common bile duct (CBD) by standard approaches had failed, due to suspected CBD obstruction. Only 4% of our cases turned out to have no biliary obstruction at all. The morbidity rate was 16%, and the mortality rate was 2%. In our series, FS raised the success rate of CBD cannulation from 90% to 96%. Ninety-five percent of successful cannulations were followed by endoscopic treatment. There were no cases of perforation or hemorrhage, and no difference in the success rate between FS in flat papillas and FS in bulging papillas, thanks, perhaps, to the technique we used. Our findings would indicate that FS is a useful procedure involving additional but not prohibitive risks. Nonetheless, it should be used only when CBD obstruction is strongly suspected and standard methods are not successful.

[Percutaneous treatment of bile duct lithiasis. Personal experience in the first 150 cases]. / Trattamento percutaneo della litiasi dei dotti biliari. Esperienza personale nei primi 150 casi.

Since 1983 we have percutaneously treated 150 cases of bile duct lithiasis in which previous endoscopic maneuvers had been incomplete or unfeasible. Complete resolution of lithiasis was obtained in 139 of 150 patients. In 6 cases only partial success was obtained but symptoms subsided. In 2 cases the treatment failed and the patients underwent surgery. Minor complications were observed in 12.6% of patients and resolved either spontaneously or by percutaneous maneuvers. Mortality rate was 2%. After a follow-up period of 6-12 months, 9 patients had a recurrence, completely resolved with further percutaneous treatment. These cases never required surgery. We obtained the best results in patients with stones residual after cholecystectomy or a iatrogenic stricture of the biliary tree. We obtained good results in massive lithiasis with combined endoscopic, surgical and radiological procedures. Morbidity and mortality rates were lower than in surgical series and similar to the endoscopic ones. The short hospitalization, the low cost and the possibility of treatment on an outpatient basis should promote the spreading of percutaneous techniques in the treatment of bile duct lithiasis.

Self-evaluation in young children.

A series of studies was conducted to examine the development of self-evaluation in children aged 1-5 years. Developmental changes in children's reactions to achievement-related outcomes were assessed in a variety of contexts, using different tasks and different criteria for success. The first study of 1-3-year-olds revealed an increased social orientation after the age of 21 months. Only children over this age were more likely to look up at the experimenter after they had produced an outcome themselves than after the same outcome had been produced by the experimenter. These older children were also more likely than younger children to call their mothers' attention to their achievements in a free-play situation. In a second study, on a task with visibly salient success versus failure outcomes, children aged 2-5 years responded to success with positive affect (e.g., smiling) and to failure with avoidance reactions (e.g., looking away from the experimenter). Praise enhanced children's positive affective reactions to success, but its effect was modest. In the final study, winning or losing on a competitive task was not understood by children below age 33 months and had no effect on their affective reactions to the task. In contrast, winning enhanced older children's pleasure in completing the task. Three stages are proposed in the development of self-evaluation. In the first stage, children experience joy in causality, but they lack the cognitive representational skills required for self-evaluation in a self-reflective sense, and they do not anticipate others' reactions to their performance. In the second stage, beginning before the age of 2 years, children anticipate adult reactions, seeking positive reactions to their successes and endeavoring to avoid negative reactions to failure. The proposed third stage involves a gradual internalization of external reactions, with children beginning to evaluate their performance and react emotionally to success and failure independently of their expectations of adult reactions. Although all studies focused on achievement outcomes, the development of self-evaluation in the moral domain may parallel this developmental sequence proposed for the achievement domain. It is also proposed that caretakers' reactions to rule violations might engender concerns about meeting adult expectations in achievement contexts.

[Early gastric cancer. Survival and prognostic factors in 95 consecutive cases]. / Early gastric cancer. Sopravvivenza e fattori prognostici in 95 casi consecutivi.

In order to characterize prognostic factors and therapeutic strategies for EGC, we have studied 95 patients operated on from 1980 to 1988. EGC was limited to the mucosa in 36% and extended to the submucosa in 64% of the cases. Lymph nodes involvement was observed in 13 patients; in 12 of them EGC extended to the submucosa. Gastric resection was performed in 73 and total gastrectomy in 22 patients with a postoperative mortality of 6% and 16% respectively. During the follow-up 8 patients died for causes related to EGC, 8 for unrelated causes. The 5 years survival rate was 79, without differences according to site, type, size and histology of EGC, lymph nodes involvement, type of gastrectomy; only EGC limited to the mucosa was associated with a better survival experience (96% vs 70% of tumors extended to the submucosa p less than 0.05). The prognosis of EGC is good and a curative surgery may be accomplished, especially if the lesion is limited to the mucosa. In EGC extended to the submucosa an accurate lymphadenectomy may further improve the prognosis, while total gastrectomy--de principe--carries a higher postoperative mortality, without significant improvement of the long term prognosis.

[Endoscopic therapy of giant choledochal calculosis]. / Terapia endoscopica della calcolosi coledocica gigante.

The paper reports the results of conventional endoscopic treatment in 100 consecutive cases of giant lithiasis of the common bile duct. A giant calculus is one whose dimensions exceed 2 cm. Endoscopic therapy proved successful in 73% of cases, with an 8% incidence of complications. The success of endoscopic treatment is related to the anatomical conditions of the biliary tract and the diameter of calculi. Mechanical lithotripsy has proved efficacious in all cases where it was used, whereas poor results were obtained using MTBE infusion through a naso-biliary tube. ESWL provided encouraging results. Cases which were not resolved using endoscopic methods were treated using intervention radiology or surgery, or both.

[Intrahepatic cholestasis in hyperthyroidism]. / Colestasi intraepatica in corso di ipertiroidismo.

Three cases of cholestatic liver disease related to hyperthyroidism are reported. Features indicative of a role of the endocrine disease in the pathogenesis of the cholestatic syndrome were the appearance of liver damage in temporal relation with the clinical onset of thyroid hyperfunction and its disappearance with the amelioration of the hyperthyroidism; the absence of congestive heart failure and of infectious, toxic or obstructive agents of liver damage; the pathological and biochemical findings of intrahepatic cholestasis. Hyperthyroidism can be rarely complicated by a severe cholestatic syndrome that may dominate the clinical presentation and course.

[Role of surgery in the multidisciplinary treatment of lithiasis of the common bile duct]. / Il ruolo della chirurgia nel trattamento multidisciplinare della litiasi della via biliare principale (VBP).

The efficacy of surgery was evaluated in 32 patients with common bile duct stones. Twenty-two patients have not undergone a previous cholecystectomy. In 13 cases an endoscopic approach was attempted before surgery. In 13 patients biliary-intestinal anastomoses were performed for large stones or bile duct strictures. In 19 cases common bile exploration with biliary drainage insertion was performed for uncomplicated biliary stones. We had no mortality and morbidity was 9%. We conclude that surgery is the treatment of choice in patients with gallbladder in situ or in cases of endoscopic failure. Endoscopic sphincterectomy may be preferred in poor-risk patients.

Percutaneous removal of biliary stones.

Since 1983 we have performed percutaneous treatment of biliary lithiasis in 97 patients. Previous retrograde endoscopic procedures were incomplete or infeasible in all patients. Immediate results were excellent resulting in complete resolution of lithiasis in 89 of 97 patients (92%). In 4 patients (4%) partial success was obtained (symptoms subsided although there were nonobstructing residual stones). Percutaneous treatment failed in 1 patient (1%). Three patients died. Complications occurred in 14 of 97 patients (14%) and mortality at 30 days was 3%. Long-term results were evaluated in 71 patients who had a least a 6-month follow-up (mean 31 months and range 6-78 months). Eight of 71 patients (11%) had recurrence of stones and 7 of these were successfully retreated transhepatically. Percutaneous removal of biliary stones is efficacious because it has a high cure rate, a low complication rate, and a mortality rate that compares favorably to that of surgery even though the patients are usually older and in poorer general condition.

Endoscopic ultrasonography in eosinophilic infiltration of gastric wall.

The case of a young man with eosinophilic gastroenteritis with primary muscularis propria involvement in the antrum and distal ileum is presented. Initial diagnosis was based uniquely on indirect clinical and radiological findings since endoscopic and histologic data had been misled by the depth of eosinophilic infiltration. In order to directly prove the diagnosis, full-thickness operative biopsy would have been necessary but was avoided on ethical grounds. Valuable information was gained through Endoscopic Ultrasonographic (EUS) study of the antrum which showed an asymmetrical thickening of the outer hypoechoic layer of the wall corresponding to the muscularis propria. The overall thickness of the antrum amounted to 0.6 cm, clearly distinct from the 0.2 cm value in uninvolved areas. Subserosal involvement was also appreciated in spite of the absence of ascites; superficial layers, mucosa and submucosa, appeared uninvolved. The patient was restudied 6 months later when symptom-free: at this time, blood eosinophilia persisted and the EUS picture was unchanged. These observations suggest that peripheral blood eosinophilia along with eosinophilic infiltration of the gastric wall are stable conditions, unrelated to symptoms. Endoscopic ultrasonography is of value in ascertaining muscular involvement in eosinophilic gastroenteritis.

[A rare complication in the suppression of a porto-systemic shunt in disabling encephalopathy]. / Considerazioni su una rara complicanza nella soppressione di shunt porto-sistemico per encefalopatia invalidante.

The authors describe an uncommon complication in a case of side-to-side portacaval shunt which was suppressed due to disabling portal-systemic encephalopathy; the patient was treated by esophageal transection with esophagogastric devascularization and nonoperative secondary occlusion of the shunt by external elastic traction on a Silastic catheter surrounding the anastomosis: a stenosis of the caval vein under traction required another operation in order to close the shunt.

[Percutaneous transhepatic cholangioscopy with an 8.5 French endoscopic catheter. Technic and preliminary results]. / Colangioscopia percutanea transepatica con catetere endoscopico 8,5 French. Tecnica e risultati preliminari.

The authors describe their preliminary personal experience in bile duct endoscopy with a very small diameter catheter (8.5 F) much less traumatic than traditional choledochoscope (15 F). The CE can be reutilized after sterilization; an angiographic guide wire up to 0.042" can be introduced in the operating channel. The CE was used in 3 patients with uncertain cholangiographic diagnosis. Instrument introduction is facilitated when simple technical manoeuvres are followed; there were no difficulties in report interpretation. An experienced interventional radiologist and an endoscopist are needed to handle the instrument. Cytologic sample, biopsy and gallstone lithotomy instruments will increase diagnostic and therapeutic possibilities of the system: for this a wider CE use in the immediate future to complete interventional radiology manoeuvres can be expected.

A histological study of hepatitis delta virus liver disease.

The histopathology of hepatitis delta virus disease was studied in carriers of HBsAg with chronic hepatitis delta antigen-positive hepatitis and in serial biopsies of patients with acute hepatitis delta virus hepatitis that progressed to chronicity. There was no histologic feature distinctive of hepatitis delta virus from other types of viral hepatitis. Biopsy specimens of patients with chronic disease exhibited portal and periportal inflammation with piecemeal necrosis, conforming to a picture of aggressive hepatitis often accompanied by cirrhosis. Characteristic was a marked intralobular infiltration by mononuclear cells and a degenerative eosinophilic change of the hepatocytic cytoplasms conducive to the formation of acidophilic bodies. Liver specimens from patients with hepatitis delta virus hepatitis exhibited aspects of focal, confluent and bridging necrosis. The disease progressed to chronicity irrespective of the original histological features. The expression of intrahepatic hepatitis delta antigen was reduced in the phase of the acute hepatitis but increased in parallel with the development of chronic active liver disease. In late-stage cirrhosis, expression of hepatitis delta antigen was usually low.

Chronic hepatitis in carriers of hepatitis B surface antigen, with intrahepatic expression of the delta antigen. An active and progressive disease unresponsive to immunosuppressive treatment.

To assess the characteristics of chronic hepatitis in hepatitis B surface antigen (HBsAg) carriers with intrahepatic delta antigen, the hepatic histologic findings of 137 patients were reviewed; 101 patients were followed for 2 to 6 years. The predominant liver disease was chronic active hepatitis in 93 patients or cirrhosis in 32; minor forms of chronic persistent or lobular hepatitis were seen in 12 patients. Eight of the 26 patients with an initial diagnosis of cirrhosis died during the follow-up period. Cirrhosis developed in 31 of 75 patients (41%) without nodular regeneration seen in the first biopsy specimen; 5 of these patients died. Treatment with prednisone or azathioprine did not induce histologic amelioration of delta hepatitis or prevent cirrhosis. Chronic HBsAg hepatitis with intrahepatic expression of the delta antigen is an active, progressive disease unresponsive to conventional immunosuppressive treatment.