Cholangioscopy using a new type of cholangioscope for the diagnosis of biliary tract disease: a case series.

We present an initial report regarding the clinical usefulness of peroral cholangioscopy, using a new type of cholangioscope, the Polyscope. Peroral cholangioscopy was performed in four patients with strictures after orthotopic liver transplantation (OLT) which were suspected of being ischemic biliary lesions, in three with indeterminate biliary strictures, in three with suspected retained bile duct stones, and in two for evaluation of the intraductal spread of adenomatous tissue after an ampullectomy. In all cases peroral cholangioscopy was performed successfully without complications. On the basis of direct viewing and/or tissue sampling a correct diagnosis was reached in all cases: in all patients who underwent OLT the strictures were not ischemic; the indeterminate strictures were all benign; and, in patients with suspected stones, complete clearance was confirmed. Intraductal spread was confirmed in one patient and excluded in the other. In our experience, peroral cholangioscopy using a Polyscope is a safe and effective method for diagnosing bile duct lesions.

Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials.

BACKGROUND AND STUDY AIMS: Precut papillotomy is considered a risk factor for endoscopic retrograde cholangiopancreatography (ERCP)-related complications; however whether the complication risk is due to precut itself or to the prior prolonged attempts is still debated; therefore, early precut implementation has been suggested to reduce the complication rate. We conducted a meta-analysis of randomized controlled trials (RCTs) comparing cannulation and complication rates of early precut implementation with persistent attempts by the standard approach. METHODS: RCTs that compared cannulation and complication rates of the early precut implementation and of persistent attempts by the standard approach were included. Summary effect sizes were estimated by odds ratio (OR) with a random-effects model and by Peto OR. RESULTS: Six RCTs with a total of 966 subjects met the inclusion criteria. Overall cannulation rates were 90 % in both randomization groups (OR 1.20; 95 % confidence interval [CI] 0.54 - 2.69). Post-ERCP pancreatitis developed in 2.5 % of patients randomized to the early precut groups and in 5.3 % of patients from the persistent attempts groups (OR 0.47; 95 %CI 0.24 - 0.91). The overall complication rates, considering pancreatitis, bleeding, cholangitis, and perforation rates, were 5.0 % in the early precut groups and 6.3 % in the persistent attempts groups (OR 0.78; 95 %CI 0.44 - 1.37). CONCLUSIONS: RCTs that investigated the issue of timing of the precut procedure were limited. Current evidence suggests that in experienced hands the early implementation of precut and persistent cannulation attempts have similar overall cannulation rates; early precut implementation reduces post-ERCP pancreatitis risk but not the overall complication rate. Further studies are needed to confirm these findings.

Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia-related bleeding in patients with liver cirrhosis.

BACKGROUND AND AIM: Gastric antral vascular ectasia (GAVE) is a cause of bleeding in patients with liver cirrhosis. Argon plasma coagulation (APC) is the most used endoscopic treatment for GAVE-related bleeding. Treatment failures have been described in patients with haemorrhagic diathesis; post-procedure complications include haemorrhages and septicaemia. The aim of the study was to evaluate efficacy and safety of APC treatment of GAVE-related bleeding in patients with liver cirrhosis. METHODS: Patients included were suffering from GAVE-related bleeding and liver cirrhosis. APC treatment was performed until eradication. Resolution of transfusion-dependent anaemia and evaluation of complications were the primary outcomes. RESULTS: 20 patients (16 Child C and 4 Child B) were enrolled and prospectively followed for a mean period of 28 months. GAVE eradication was achieved in all patients after a median of 3 sessions (range 1-10). Resolution of anaemia was achieved in 18 patients. Six patients had relapse of GAVE after a mean of 7.7 months, successfully retreated by APC. Hyperplastic polyps developed in 3 patients causing active bleeding in 2 cases. Five patients had liver transplants and 1 had a relapse of GAVE after transplantation. CONCLUSION: APC is an effective and safe endoscopic treatment for GAVE in patients with liver cirrhosis.

Alcohol use is a risk factor for a first generalized tonic-clonic seizure. The ALC.E. (Alcohol and Epilepsy) Study Group.

We performed a multicenter case-control study to estimate whether chronic alcoholism and alcohol consumption are risk factors for developing a first generalized tonic-clonic seizure (GTCS). We studied 237 first-seizure patients (158 men, 79 women) matched to 474 hospital controls for center, sex, age (+/-5 years), and weekday of the seizure. The risk of first GTCS in alcoholics was greater than in non-alcoholics for men (odds ratio, 6.8; 95% confidence limits, 3.6-13.0) and women (6.8, 1.6-32.6). The odds ratio (both sexes) was 1.2 (0.8-1.8) for an average daily intake of absolute alcohol of 1 to 25 g/day and rose with the amount of alcohol consumed daily: 1.3 (0.8-2.1) for 26 to 50 g/day, 3.0 (1.7-5.4) for 51 to 100 g/day, 7.9 (2.9-21.9) for 101 to 200 g/day, and 16.6 (1.9-373.4) for >200 g/day. Our study provides evidence of a powerful association between alcohol use, alcoholism, and the first GTCS.

[Pseudo-Cushing syndrome. Physiopathologic aspects and differential diagnosis]. / La sindrome da pseudo-Cushing. Aspetti fisiopatologici e diagnosi differenziale.

Pseudo-Cushing Syndromes (PCS) are a heterogeneous group of disorders, including alcoholism and depression, that share many of the clinical and biochemical features of Cushing's Syndrome (CS). It has been suggested that hypercortisolism of PCS may be the result of increased hypothalamic corticotropin-releasing hormone secretion in the context of a hypothalamic-pituitary-adrenal axis that is otherwise normally constituted. The substantial overlap in clinical features and daily urinary free cortisol levels between several patients with CS and those with PCS can make the differential diagnosis difficult. The most accurate tests in the distinction of CS from alcohol-induced PCS are dexamethasone-CRH and a midnight serum cortisol measurement. In depressed patients, the insulin tolerance test may be useful, although some overlap may exist. This brief review summarises the principal pathophysiological events of PCS and provides a useful strategy for differential diagnosis.

Comparison between computed tomography and magnetic resonance data and pathologic findings in substernal goiters.

Computed Tomography (CT) and Magnetic Resonance (MR) permit the acquirement of important diagnostic elements for the anatomo-topographic staging of substernal goiters, and for their characterization. The authors compared data obtained by CT and MR with intraoperative anatomo-topographic findings and definitive histology in 28 patients with substernal goiters. CT was performed in all these patients while MR only in 9. The results obtained showed an accuracy of 85.7% for CT and 100% for MR regarding the anatomo-topographic correspondence with intraoperative findings, without a significant statistical difference between these two diagnostic procedures. MR is more accurate than CT in showing the vascular dislocations. CT and MR have an accuracy of 82.1% and 77.7% respectively comparing their findings with histologic results obtained in operative specimens, without a significant statistical difference. In conclusion MR has to be considered the more accurate diagnostic procedure and therefore recommended in the study of patients with substernal goiters, while CT can be performed only in selected patients.

[Role of magnetic resonance in the evaluation of thrombosis of large thoraco-abdominal vessels]. / Ruolo della risonanza magnetica nella valutazione della trombosi dei grossi vasi toraco-addominali.

Magnetic resonance (MR) has been found to be a method suitable for the study of the vascular system since it permits to distinguish between moving (circulating blood) and static (thrombi, atherosclerotic plaques, intimal flaps) tissues. The sequences used for the evaluation of thrombi are Spin Echo (SE) and Gradient Echo (GE). If both sequences are used the diagnosis of thrombosis is considerably more reliable. The limits of the technique are represented by spatial resolution which is not optimal and makes the evaluation of thrombi in small or medium-size vessels difficult; further, small or non occlusive thrombi may be difficult to identify. Nowadays, with the technique of angiography with magnetic resonance (AMR) it has become possible to obtain high quality images of the vessels of the head, neck, abdomen and limbs. Further improvements of the AMR technique are likely to replace diagnostic angiography.

[A comparison between computed tomography and magnetic resonance in the verification of prolactinomas]. / Confronto tra tomografia computerizzata e risonanza magnetica nell'accertamento dei prolattinomi.

First, computer tomography and subsequently magnetic resonance have profoundly changed the diagnostic protocol for the study pituitary pathology. Conventional X-ray and examination with the use of contrast media are being employed less and less. Tomographic techniques (CT and RM) permit direct identification of anomalies as well as precise evaluation of their relationship with surrounding structures.

[Steroid therapy and adrenal function]. / Terapia steroidea e funzione surrenalica.

Glucocorticoids are frequently used for both diagnostic and therapeutic purposes. Their action mimics endogenous glucocorticoid actions by altering the activity of the hypothalamic-pituitary-adrenal (HPA) axis. Therefore, they can be responsible for iatrogenic diseases, particularly if used at high doses and for a long time. The aim of this brief review is to show the main pharmacological characteristics and the endocrine effects of glucocorticoids. The HPA axis insufficiency, related to acute glucocorticoid withdrawal, is also discussed.