Consecutive versus separate sessions of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic choledocholithiasis.

BACKGROUND: Common bile duct (CBD) stones are a potentially life-threatening medical condition. Patients with proven CBD stones should undergo stone extraction. The aim of this study was to evaluate whether performing endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic CBD stones in a single session reduces complications related to postponing treatment due to separate EUS and ERCP sessions, and to assess the safety in both options. METHODS: A total of 151 patients with EUS-proven CBD stones, with subsequent ERCP, treated in our department between January 2005 and December 2011 were included. Complications related to the procedures or sedation and complications due to the CBD stones when EUS and ERCP were not performed in a single session were assessed and compared to complications when the two procedures were performed in one session. RESULTS: In total, 149 patients of the 151 (98.7 %) had a successful ERCP. Four (5 %) patients in the separate-session group (B) had a major complication compared to none in the single-session group (A) (p > 0.05). Group B received 14 % more midazolam during ERCP than group A (p < 0.05). No sedation-related complications were noted in either group. Eleven of the 80 patients in group B (13.8 %) experienced complications while waiting for ERCP compared to none in group A (p = 0.001, OR = 2.17, CI = 1.06-4. CONCLUSIONS: EUS and ERCP done in a single session proved to be safe, with no increase in sedation- or procedure-related complications. Postponing treatment for symptomatic CBD stones exposes the patient to biliary complications, especially cholangitis.

[Thiopurine-induced hyperammonaemic encephalopathy in a patient with Crohn's disease].

Thiopurine drugs, azathioprine (Imuran) and 6-mercaptopurine (6-MP), are immunomodulators that have been shown to be effective at inducing and maintaining remission in inflammatory bowel disease. Although usually well-tolerated, the occurrence of side effects, typically myelotoxicity and hepatotoxicity, is a major drawback. The side effects can be classified as dose-dependent and independent. Both cholestatic hepatitis and endothelial injury, leading to vascular congestion and nodular regenerative hyperplasia, have been described during therapy with thiopurines, which can end up with portal hypertension. These injuries are potentially mediated by different metabolites. In this article we present a case of hyperammonaemic encephalopathy during therapy with 6-MP, possibly the first recorded in the literature, which probably resulted from the combination of thiopurine-induced liver injury with portal hypertension and the presence of spontaneous portosystemic venous shunts.

[ERCP for benign disease in the elderly: a good prognosis].

BACKGROUND: biliary disease in the elderly (over 80) are common and can be a diagnostic and therapeutic challenge. METHODS: medical records of patients age 80 and older who underwent endoscopic retrograde cholangiopancreatography (ERCP) for benign biliary disease from January 2000 to April 2005 were studied retrospectively. RESULTS: 100 patients of whom data was obtainable underwent 133 procedures. The indications for the procedure included suspicion of common bile duct stones (94.4%), biliary stend insertion and replacement (4%), non-malignant obstructive jaundice (0.8%) and echinococcal cyst (0.9%). Midaozolam (100%) and fentanyl (100%) were used for conscious sedation. Patient tolerance was good in 100% of procedures. Therapeutic procedures (endoscopic sphincterotomy, stent insertion or replacement) were indicated in 88% of procedures, and successful in 96.8% of cases. Short term complications (up to 30 days after procedure) occurred in 4/5% of ERCP procedures. There was no early mortality. CONCLUSIONS: ERCP is a safe procedure in the elderly with a low complication rate and good therapeutic efficacy.

Fasting hypoglycemia in solitary fibrous tumor of the peritoneum: a diagnostic clue for an emergent situation.

Solitary fibrous tumors are rare fibrous tumors found in various anatomic sites. Extrathoracic neoplasms are often symptomatic at presentation, with paraneoplastic hypoglycemia being reported as one of the associated clinical features of such slow-growing tumors. As hypoglycemia can be an emergent clinical situation, we describe a patient with a giant abdominal tumor who presented with a symptomatic hypoglycemia, which might be regarded as a diagnostic clue.