RESUMEN
BACKGROUND: Biliary tract cancer (BTC) and benign biliary strictures can be difficult to differentiate using standard tumour markers such as serum carbohydrate antigen 19-9 (CA19-9) as they lack diagnostic accuracy. METHODS: Two-dimensional difference gel electrophoresis and tandem mass spectrometry were used to profile immunodepleted serum samples collected from cases of BTC, primary sclerosing cholangitis (PSC), immunoglobulin G4-associated cholangitis and healthy volunteers. The serum levels of one candidate protein, leucine-rich α-2-glycoprotein (LRG1), were verified in individual samples using enzyme-linked immunosorbent assay and compared with serum levels of CA19-9, bilirubin, interleukin-6 (IL-6) and other inflammatory markers. RESULTS: We report increased LRG1, CA19-9 and IL-6 levels in serum from patients with BTC compared with benign disease and healthy controls. Immunohistochemical analysis also demonstrated increased staining of LRG1 in BTC compared with cholangiocytes in benign biliary disease. The combination of receiver operating characteristic (ROC) curves for LRG1, CA19-9 and IL-6 demonstrated an area under the ROC curve of 0.98. In addition, raised LRG1 and CA19-9 were found to be independent predictors of BTC in the presence of elevated bilirubin, C-reactive protein and alkaline phosphatase. CONCLUSION: These results suggest LRG1, CA19-9 and IL-6 as useful markers for the diagnosis of BTC, particularly in high-risk patients with PSC.
Asunto(s)
Neoplasias del Sistema Biliar/diagnóstico , Antígeno CA-19-9/sangre , Colangitis Esclerosante/diagnóstico , Colangitis/diagnóstico , Glicoproteínas/sangre , Interleucina-6/sangre , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores de Tumor/análisis , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Postulated mechanisms of alcoholic pancreatitis include (i) zymogen granule fragility facilitating intracellular activation of digestive enzymes and (ii) ductular obstruction by protein plugs. GP2, a pancreatic glycoprotein, stabilizes zymogen granule membranes and is an important constituent of pancreatic protein plugs. Therefore, this study examined the pancreatic content and messenger RNA levels of GP2 after chronic ethanol administration. Rats were fed liquid diets with or without ethanol, for four weeks. GP2 levels in pancreatic homogenates, crude zymogen granules and zymogen granule membrane fractions were assessed by immunoblotting. Messenger RNA levels for GP2 were measured by Northern and dot blotting of pancreatic RNA. Pancreatic GP2 levels were lower in ethanol-fed rats than in controls (GP2 levels expressed as % of control: 38.75 +/- 5.8, p < 0.001 in homogenate; 31.28 +/- 3.5, p < 0.0005 in crude zymogen granules and 22.89 +/- 5.4, p < 0.0005 in zymogen granule membranes). Messenger RNA levels for GP2 were unchanged after ethanol feeding. Chronic ethanol consumption decreases GP2 content of pancreatic homogenate and zymogen granules. This decrease could (i) result from an increased release into pancreatic juice thereby favouring protein plug formation and (ii) impair zymogen granule stability. Both these mechanisms could potentiate pancreatic damage.
Asunto(s)
Etanol/farmacología , Páncreas/efectos de los fármacos , Fosforilasas/metabolismo , Animales , Northern Blotting , Etanol/administración & dosificación , Masculino , Páncreas/enzimología , Fosforilasas/genética , ARN Mensajero/genética , ARN Mensajero/metabolismo , Ratas , Ratas Sprague-DawleyRESUMEN
Acute pancreatitis is a common cause for presentation to emergency departments. Common causes in Western societies include biliary pancreatitis and alcohol (the latter in the setting of chronic pancreatitis). Acute pancreatitis also follows endoscopic retrograde pancreatography in 5 to 10% of patients, a group that could potentially benefit from prophylactic treatment. Although episodes of pancreatitis usually run a relatively benign course, up to 20% of patients have more severe disease, and this group has significant morbidity and mortality. Therefore, attempts have been made to identify, at or soon after presentation, those patients likely to have a poor outcome and to channel resources to this group. The mainstay of treatment is aggressive support and monitoring of those patients likely to have a poor outcome. Pharmacotherapy for acute pancreatitis (both prophylactic and in the acute setting) has been generally disappointing. Efforts initially focused on protease inhibitors, of which gabexate shows some promise as a prophylactic agent. Agents that suppress pancreatic secretion have produced disappointing results in human studies. Infection of pancreatic necrosis is associated with high mortality and requires surgical intervention. In view of the seriousness of infected necrosis, the use of prophylactic antibacterials such as carbapenems and quinolones has been advocated in the setting of pancreatic necrosis. Similarly, data are accumulating to support the use of prophylactic antifungal therapy. Recently, it has become apparent that the intense inflammatory response associated with acute pancreatitis is responsible for much of the local and systemic damage. With this realisation, future efforts in pharmacotherapy are likely to focus on suppression or antagonism of pro-inflammatory cytokines and other inflammatory mediators. Similarly, animal studies have demonstrated the importance of oxidative stress in acute pancreatitis, although to date there is a paucity of information regarding the efficacy of antioxidants. Although the clinical course for most patients with acute pancreatitis is mild, severe acute pancreatitis continues to be a clinical challenge, requiring a multidisciplinary approach of physician, intensivist and surgeon.
Asunto(s)
Corticoesteroides/uso terapéutico , Pancreatitis Aguda Necrotizante , Inhibidores de Proteasas/uso terapéutico , APACHE , Animales , Colangiopancreatografia Retrógrada Endoscópica , Humanos , Pancreatitis Aguda Necrotizante/complicaciones , Pancreatitis Aguda Necrotizante/diagnóstico , Pancreatitis Aguda Necrotizante/tratamiento farmacológico , Pronóstico , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
OBJECTIVES: To determine the effect of endoscopic ultrasonography (EUS) on endoscopic drainage of pancreatic pseudocysts and to determine patency with fistula dilation and placement of multiple stents. PATIENTS AND METHODS: Between September 1995 and January 1999, 19 patients underwent endoscopic drainage of pancreatic pseudocysts, 17 of whom were assessed by EUS before drainage. Radial EUS scanning was used to detect an optimal site of apposition of pseudocyst and gut wall, free of intervening vessels. A fistula was created with a fistulatome, followed by balloon dilation of the fistula tract. Patency was maintained with multiple double pigtail stents. The primary goal of this retrospective study was to determine whether EUS affected the practice of endoscopic drainage of pancreatic pseudocysts. RESULTS: In 3 patients, drainage was not attempted based on EUS findings. In the other 13 patients (14 pseudocysts), creation of a fistula was successful on 13 occasions, and no immediate complications occurred. However, 1 patient subsequently developed sepsis that required surgery. All other patients were treated with balloon dilation, multiple stents, and antibiotics, with no septic complications. Of 14 pseudocysts (in 13 patients), 13 (93%) resolved. CONCLUSIONS: Results of EUS may alter management of patients considered for endoscopic drainage of pancreatic pseudocysts. Endoscopic ultrasonography was useful for selecting an optimal and safe drainage site. The combination of balloon dilation, multiple stents, and antibiotics appears to resolve pancreatic pseudocysts without septic complications.
Asunto(s)
Cateterismo/métodos , Drenaje/métodos , Endosonografía/métodos , Seudoquiste Pancreático/diagnóstico por imagen , Seudoquiste Pancreático/cirugía , Ultrasonografía Intervencional/métodos , Adulto , Anciano , Profilaxis Antibiótica , Cateterismo/instrumentación , Colangiopancreatografia Retrógrada Endoscópica , Drenaje/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Stents , Resultado del TratamientoRESUMEN
Both ethanol abuse and protein deficiency are well known associations of chronic pancreatitis. An early event in chronic pancreatitis is the deposition of protein plugs in small pancreatic ducts, leading to ductular obstruction and acinar cell damage. Lithostathine, a pancreatic secretory protein, is a major organic component of protein plugs. The aim of this study was to determine the effect of chronic ethanol administration and dietary protein deficiency, separately and in combination, on messenger RNA (mRNA) levels for pancreatic lithostathine. Male Sprague-Dawley rats were fed in groups of four, for four weeks, protein sufficient and protein deficient diets with or without ethanol. Messenger RNA levels for pancreatic lithostathine were assessed in all four groups. Both ethanol and protein deficiency, separately and in combination, increased mRNA levels for lithostathine. Thus, both chronic ethanol consumption and dietary protein deficiency increase the capacity of the pancreatic acinar cell to synthesize lithostathine.
Asunto(s)
Alcoholismo/metabolismo , Proteínas de Unión al Calcio/metabolismo , Etanol/toxicidad , Proteínas del Tejido Nervioso , Páncreas/efectos de los fármacos , Páncreas/metabolismo , Pancreatitis/metabolismo , Deficiencia de Proteína/metabolismo , ARN Mensajero/metabolismo , Alcoholismo/complicaciones , Animales , Secuencia de Bases , Peso Corporal/efectos de los fármacos , Enfermedad Crónica , Litostatina , Masculino , Datos de Secuencia Molecular , Tamaño de los Órganos/efectos de los fármacos , Pancreatitis/etiología , Ratas , Ratas Sprague-DawleyRESUMEN
The role of therapeutic endoscopy in the treatment of acute and chronic pancreatitis has expanded dramatically over the past 10 years. Drainage of pseudocysts and even organized pancreatic necrosis when localized are becoming commonplace. Other areas in which therapeutic endoscopy has been shown to be efficacious include severe biliary pancreatitis, pancreatic duct disruptions, strictures, and obstructive calculi. Its role in the management of acute recurrent pancreatitis with presumed Oddi's sphincter dysfunction or pancreas divisum continues to be defined. The cost-effectiveness and minimally invasive nature of endoscopic therapy compared with surgery should ensure the continued development of these techniques. More controlled, prospective data are required.
Asunto(s)
Drenaje/métodos , Endoscopía , Pancreatitis/cirugía , Enfermedad Aguda , Cálculos/complicaciones , Cálculos/diagnóstico por imagen , Cálculos/cirugía , Colangiopancreatografia Retrógrada Endoscópica , Enfermedad Crónica , Humanos , Páncreas/anomalías , Páncreas/cirugía , Conductos Pancreáticos/cirugía , Seudoquiste Pancreático/cirugía , Pancreatitis/diagnóstico por imagen , Pancreatitis/etiología , Esfinterotomía EndoscópicaRESUMEN
Endoscopic ultrasound (EUS) comprises several techniques of performing high-frequency ultrasound via an endoscope placed in the gastrointestinal tract (oesophagus, stomach, duodenum and pancreaticobiliary tree and rectum). It has rapidly become an important tool in the investigation of a variety of lumenal disorders as well as locoregional staging of gastrointestinal malignancies. Needle biopsy of peri-intestinal structures, such as lymph nodes and pancreatic masses, can also be performed under real-time ultrasound control. To date, the utilization of this technology in Australia has been limited by cost constraints and a paucity of training opportunities. EUS continues to be a rapidly growing area in clinical gastroenterology. Recent studies continue to define its role, particularly in the loco-regional staging of a variety of malignancies. In addition, new instruments permit tissue sampling and a variety of therapeutic manoeuvres under direct ultrasound guidance.33; 26-32)
Asunto(s)
Neoplasias del Sistema Digestivo/diagnóstico por imagen , Endosonografía/métodos , Biopsia/métodos , Neoplasias del Sistema Digestivo/patología , Neoplasias del Sistema Digestivo/terapia , Endoscopios , Endosonografía/efectos adversos , Humanos , Ganglios Linfáticos/diagnóstico por imagen , Metástasis LinfáticaRESUMEN
Many technical advances have offered enhanced capabilities in noninvasive imaging of the pancreas. Although these technical advances are impressive, current studies do not always define clearly the benefits that these advances will confer in patient management. A critical overview of these imaging modalities is offered here, with respect to diagnosis and patient management. Outcomes from various studies are summarized for modalities including transabdominal ultrasound, computed tomography, magnetic resonance imaging with and without pancreatography, and positron emission tomography.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica/métodos , Enfermedades Pancreáticas/diagnóstico , Tomografía Computarizada por Rayos X , Humanos , Imagen por Resonancia Magnética/métodos , Enfermedades Pancreáticas/diagnóstico por imagen , Enfermedades Pancreáticas/terapia , Tomografía Computarizada de Emisión , Tomografía Computarizada por Rayos X/métodos , Ultrasonografía/métodosRESUMEN
The periampullary region is the most common site of adenomatous change in the small bowel, particularly in patients with familial adenomatous polyposis (FAP) syndromes. These lesions have been shown to progress to malignancy in a manor analogous to colonic polyps. Following colectomy, the periampullary region is the commonest site of gastrointestinal malignancy in FAP patients. The periampullary region is within easy reach of forward- and side-viewing endoscopes and therefore endoscopic surveillance in FAP patients is both easy and prudent. Furthermore, there is accumulating evidence that endoscopic resection and/or ablation are the treatment of choice for periampullary adenomas. However, the optimal timing of surveillance and best methods of ablation remain to be determined. This paper reviews the literature on the endoscopic management of periampullary adenoma as well as outlining our current approach to this challenging problem.
Asunto(s)
Adenoma/cirugía , Poliposis Adenomatosa del Colon/cirugía , Ampolla Hepatopancreática , Neoplasias del Conducto Colédoco/cirugía , Neoplasias Duodenales/cirugía , Endoscopía , Adenoma/patología , Poliposis Adenomatosa del Colon/patología , Neoplasias del Conducto Colédoco/patología , Neoplasias Duodenales/patología , Endoscopía Gastrointestinal , HumanosRESUMEN
Ethanol abuse is a well known association of pancreatitis. Research into the pathogenesis of alcoholic pancreatitis has generally followed two directions. Firstly, factors which may predispose alcoholics to pancreatitis have been examined. To date, these studies have been negative and the predisposing factor(s) remain unknown. The second approach has involved studies on the constant metabolic effects of ethanol on the pancreas which may render the acinar cell susceptible to digestive enzyme induced injury. Recently developed models of experimental pancreatitis have implicated intracellular activation of digestive enzymes by lysosomal enzymes as an early event. Using the Lieber-DeCarli model of ethanol administration to rats, a number of changes have been described in pancreatic acinar cells which may predispose the gland to autodigestion. These changes include: (1) increased glandular content of digestive enzymes as a result of increases in mRNA levels for these enzymes; (2) increased glandular content of the lysosomal enzyme cathepsin B (known to be capable of activating trypsinogen); (3) increased fragility of lysosomes possibly mediated by cholesteryl esters and fatty acid ethyl esters; and (4) increased fragility of zymogen granules. These effects of ethanol constitute a "primed" setting (the "Drinker's Pancreas") for autodigestion. Triggering factors for autodigestion in this setting have not yet been identified.
Asunto(s)
Etanol/toxicidad , Páncreas/efectos de los fármacos , Páncreas/lesiones , Animales , Precursores Enzimáticos/metabolismo , Etanol/metabolismo , Humanos , Lisosomas/efectos de los fármacos , Modelos Biológicos , Páncreas/metabolismo , Pancreatitis Alcohólica/etiología , Pancreatitis Alcohólica/metabolismo , Pancreatitis Alcohólica/patología , RatasRESUMEN
Thirty-one patients were randomized during 39 episodes of bleeding to receive either 1 g of intravenous cefotaxime (19 patients) or no antibiotic (20 patients) immediately before emergency endoscopic sclerotherapy. Blood was obtained for culture before and at 5 minutes, 4 hours, and 24 hours after the procedure. Specimens for culture were taken from the endoscope tip and channel, water bottle, and injection needle after sclerotherapy. When ascites was present (5 patients in the antibiotic group, 7 in the control group), fluid was obtained by paracentesis before endoscopy and at 4 and 24 hours. Bacteremia occurred in 1 of 19 patients in the antibiotic group (5.3%), compared with 6 of 19 in the control group (31.6%; p = .04). The cultured organisms were oral flora and usually also contaminated the endoscope and needle. No bacteria were cultured from ascitic fluid in any patient nor was the ascitic fluid white cell count elevated. Clinical infection attributable to sclerotherapy did not develop in any patient. In conclusion, the frequency of bacteremia after endoscopic sclerotherapy for bleeding esophageal varices can be reduced by prophylactic administration of intravenous cefotaxime. However, this may not be clinically relevant, given the absence of bacterascites and infection in this study. These findings do not support the routine use of antibiotics before sclerotherapy.
Asunto(s)
Ascitis/etiología , Ascitis/prevención & control , Bacteriemia/etiología , Bacteriemia/prevención & control , Infecciones Bacterianas/etiología , Infecciones Bacterianas/prevención & control , Cefotaxima/administración & dosificación , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Escleroterapia/efectos adversos , Endoscopía Gastrointestinal , Contaminación de Equipos , Femenino , Humanos , Inyecciones Intravenosas , Masculino , Persona de Mediana EdadRESUMEN
Considerable variability has been reported in the frequency and specificity of anti-neutrophil cytoplasmic antibody with a perinuclear staining pattern (pANCA) in patients with chronic liver disease, especially in primary sclerosing cholangitis (PSC), and in inflammatory bowel disease. This study examines the presence of pANCA in patients with these disorders, in particular those with PSC complicated by other biliary disease, and also patients who had undergone orthotopic liver transplantation. An indirect immunofluorescent technique was used to measure pANCA with serum diluted 1:20. Ten of 39 (26%) patients with PSC had detectable pANCA, as did two of nine (22%) with autoimmune chronic active hepatitis (AICAH) but none of the 51 patients with other forms of chronic liver disease. The presence of pANCA was significantly more frequent in patients who had PSC with biliary tract complications, in particular calculi (seven of 16 with vs three of 23 without; P = 0.03). Eight of the 12 pANCA-positive patients with PSC or AICAH had undergone hepatic transplantation. This was more likely than in patients with PSC or AICAH who were pANCA negative (10 of 36; P = 0.02). To date, pANCA has been detected after transplantation in four patients with PSC and one with AICAH. In patients with PSC or AICAH, pANCA should be sought as a marker of prognosis.
Asunto(s)
Autoanticuerpos/análisis , Colangitis Esclerosante/inmunología , Adulto , Anciano , Anticuerpos Anticitoplasma de Neutrófilos , Enfermedades de las Vías Biliares/complicaciones , Biomarcadores , Colangitis Esclerosante/complicaciones , Colitis Ulcerosa/complicaciones , Colitis Ulcerosa/inmunología , Enfermedad de Crohn/complicaciones , Femenino , Humanos , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Periodo PosoperatorioRESUMEN
OBJECTIVES: Periampullary adenomas are an increasingly recognized condition, both in those with familial adenomatous polyposis syndromes (FAP) as well as sporadic cases. Endoscopic management has been advocated for these lesions without differentiating between these two patient groups regarding aim of therapy. The aims of this study were to determine the safety and effectiveness of endoscopic surveillance and ablative therapy of periampullary adenomas in patients with both sporadic and FAP-associated lesions. METHODS: Retrospective analysis of 59 patients with FAP and 32 with sporadic lesions who were all enrolled in a program of endoscopic surveillance and ablative therapy. Median follow-up was 24 months (range, 1-134 months). RESULTS: Ampullary ablative therapy has resulted in return to normal histology in 44 and 34% of sporadic and FAPassociated lesions, respectively. Complications of endoscopic therapy were mild in 12 patients and severe in 3 patients: the latter category involved one occurrence of asymptomatic duodenal stenosis and one occurrence of postcoagulation syndrome--both after Nd-YAG laser therapy-and necrotizing pancreatitis after ampullary biopsy in one patient. Thirteen patients have been referred for surgical intervention. There has been no mortality and no cases of advanced malignancy missed by endoscopy. CONCLUSIONS: Endoscopic surveillance and ablative therapy of periampullary lesions is safe and can be effective, although eradication of ampullary tissue requires multiple ablative sessions.
Asunto(s)
Adenoma/diagnóstico , Adenoma/terapia , Ampolla Hepatopancreática/patología , Neoplasias del Conducto Colédoco/terapia , Endoscopía del Sistema Digestivo/métodos , Adenoma/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Colangiopancreatografia Retrógrada Endoscópica , Neoplasias del Conducto Colédoco/diagnóstico , Neoplasias del Conducto Colédoco/cirugía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Complications with EUS-guided fine needle aspiration cytology (EUS-guided FNA) are rare and include perforation, infection, pancreatitis, and intraluminal bleeding. To date, the ultrasound appearance and clinical significance of perilesional bleeding during EUS-guided FNA have not been described. The aim of this study was to analyze the frequency of acute extraluminal hemorrhage associated with EUS-guided FNA. METHODS: From September 1998 to October 1999 EUS-guided FNA was performed during 227 of 1104 EUS procedures. Patient follow-up and complications were recorded and retrospectively analyzed. OBSERVATIONS: Three patients were identified with acute extraluminal hemorrhage at the site of the aspiration during EUS (frequency 1.3%: 95% CI [0%, 2.8%]). The bleeding manifested as an expanding echopoor region adjacent to the sampled lesion. No clinically recognizable sequela arose from the bleeding. All patients were treated with a short course of antibiotics and outpatient observation. Preprocedure coagulation and platelet assessment did not predict which patients were at risk for this complication. CONCLUSION: Acute extraluminal hemorrhage occurring during EUS-guided FNA is a rare complication with a characteristic ultrasound appearance. Recognition of this event might be important to allow the endoscopist to terminate the procedure and thereby minimize the potential for more serious bleeding.
Asunto(s)
Biopsia con Aguja/efectos adversos , Endosonografía , Hemorragia Gastrointestinal/etiología , Enfermedad Aguda , Adolescente , Anciano , Anciano de 80 o más Años , Biopsia con Aguja/métodos , Femenino , Hemorragia Gastrointestinal/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Celiac plexus neurolysis, a chemical splanchnicectomy of the celiac plexus, is used to treat pain caused by pancreatic cancer. Most commonly, celiac plexus neurolysis is performed percutaneously under CT or fluoroscopic guidance, but can also be performed with EUS. The aim of this study was to prospectively assess the efficacy of EUS celiac plexus neurolysis in the management of pain caused by pancreatic cancer. METHODS: In this prospective study conducted in a community-based referral hospital, 58 patients with painful and inoperable pancreatic cancer were evaluated at 8 observation points before and after EUS celiac plexus neurolysis for up to 6 months. The following data were collected: age, gender, tumor location, vascular invasion, adjuvant therapy, and laboratory tests including prothrombin time, and complete blood counts were obtained at baseline (before EUS celiac plexus neurolysis); pain scores, morphine use, and adjuvant therapy were assessed at each observation. RESULTS: Pain scores were lower (p = 0.0001) 2 weeks after EUS celiac plexus neurolysis, an effect that was sustained for 24 weeks when adjusted for morphine use and adjuvant therapy. Forty-five of the 58 patients (78%) experienced a decline in pain scores after EUS celiac plexus neurolysis. Chemotherapy with and without radiation also decreased pain after EUS celiac plexus neurolysis (p = 0.002). Procedure-related transient abdominal pain was noted in 5 patients; there were no major complications. CONCLUSIONS: EUS celiac plexus neurolysis is safe and controls pain caused by unresectable pancreatic cancer.
Asunto(s)
Plexo Celíaco , Cuidados Paliativos/métodos , Neoplasias Pancreáticas/fisiopatología , Anciano , Estudios de Cohortes , Endosonografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Dimensión del Dolor , Neoplasias Pancreáticas/terapia , Estudios Prospectivos , Análisis de Regresión , Simpatectomía Química , Factores de TiempoRESUMEN
BACKGROUND: Upper gastrointestinal (UGI) bleeding is a relatively common and potentially fatal complication of coronary artery bypass graft (CABG) surgery. However, little is known of this problem, including its incidence, predisposing factors and safety of endoscopy in these patients. AIM: To document the incidence, site, predisposing factors and outcome of UGI bleeding following CABG surgery. Also, to assess the safety of UGI endoscopy in these patients. METHOD: Retrospective study of UGI haemorrhage following CABG at one institution between 1976 and 1991. RESULTS: Fifty-five of 10,573 patients (0.5%) suffered a major UGI haemorrhage (as defined by need for transfusion or presence of melaena or haematemesis associated with hypotension). Of 51 patients undergoing endoscopy or laparotomy, 42 (82%) bled from duodenal ulceration. Five patients bled from gastric ulcers and one each from oesophagitis and Mallory Weiss tear. Nine patients underwent endoscopic therapy, which initially arrested haemorrhage in eight patients. However, three patients rebled and required surgery. Eight patients underwent surgery as initial therapy, resulting in an overall surgical rate of 20%. One patient died due to multi system failure following surgery. There were no complications from endoscopy. Patients who bled were more likely to have received inotropic support post-operatively prior to the haemorrhage (p < 0.05) and tended to be older than controls (mean age 65.6 years vs 58.7 years, p < 0.01). Twenty-one of the patients (38%) who bled had a past history of peptic ulceration or dyspepsia compared with 9% of controls (p < 0.001). Seven (12.5%) had previously bled from peptic ulceration. Patients who bled were less likely to have received H2-receptor antagonists in the perioperative period than controls (4% vs 20%, p < 0.05). CONCLUSION: Upper GI haemorrhage following CABG is relatively frequent. It is usually secondary to duodenal ulceration. Endoscopy is a safe procedure in this patient group. Mortality did not differ between index patients who suffered a UGI haemorrhage and controls undergoing CABG who did not bleed.
Asunto(s)
Puente de Arteria Coronaria/efectos adversos , Hemorragia Gastrointestinal/etiología , Anciano , Úlcera Duodenal/complicaciones , Femenino , Humanos , Masculino , Estudios RetrospectivosRESUMEN
Alcoholic pancreatitis is a major, often lethal complication of alcohol abuse. Until recently it was generally accepted that alcoholic pancreatitis was a chronic disease from the outset. However, there is now emerging evidence in favour of the necrosis-fibrosis hypothesis that alcoholic pancreatitis begins as an acute process and that repeated acute attacks lead to chronic pancreatitis, resulting in exocrine and endocrine failure. Over the past 10-15 years, the focus of research into the pathogenesis of alcoholic pancreatitis has shifted from possible sphincteric and ductular abnormalities to the acinar cell itself which has increasingly been implicated as the initial site of injury. Recent studies have shown that the acinar cell can metabolize alcohol at rates comparable to those observed in hepatocytes. In addition, it has been demonstrated that alcohol and its metabolites exert direct effects on the pancreatic acinar cell which may promote premature digestive enzyme activation and oxidant stress. The challenge remains to identify predisposing and triggering factors in this disease.
RESUMEN
BACKGROUND: EUS requires a significant capital outlay. The ability to perform high-resolution phased array scanning and Doppler interrogation by using a catheter that interfaces with a standard US console could increase the accessibility of EUS. Recently, an electronic phased-array US catheter was developed for intracardiac use. To date, this technology has not been applied to the GI tract. The aim of this study is to determine the feasibility and imaging characteristics of a new phased array scanning US catheter in the GI tract. METHODS: Swine were placed under general anesthesia. This study used a 100 cm, 10F, torquable catheter with 4-way tip deflection to greater than 90 degrees. The catheter tip houses a phased vector array transducer with variable frequency (5.5-10 MHz) and variable focal distance. It has pulsed/color and power Doppler capability. The probe was passed through a therapeutic flexible sigmoidoscope into the upper GI tract. Acoustic coupling was achieved via a condom filled with water or by gastric water infusion. Needle visualization experiments were performed with a second endoscope (also passed per oral) with a standard EUS-guided fine needle aspiration needle. RESULTS: Acoustic coupling was easily achieved. Resolution of the GI wall into characteristic layers (esophagus 5, stomach 7) was demonstrated. At 5.5 MHz, tissue resolution and Doppler imaging were excellent to greater than 10 cm from the transducer. A 22-gauge EUS-guided fine needle aspiration needle was easily visualized at depth greater than 4 cm. Flow in gastric, hepatic, and pancreatic parenchymal vessels approximately 1 mm diameter was visualized by using power and color Doppler. CONCLUSIONS: This 10F array US catheter is capable of high-resolution two-dimensional imaging of the gut wall as well as high-quality Doppler imaging. The Doppler capabilities of this equipment may have new GI applications.
Asunto(s)
Cateterismo/métodos , Endoscopía Gastrointestinal/métodos , Ultrasonografía Doppler en Color/métodos , Animales , Biopsia con Aguja/métodos , Esófago/diagnóstico por imagen , Estudios de Factibilidad , Hígado/irrigación sanguínea , Hígado/diagnóstico por imagen , Circulación Hepática , Sensibilidad y Especificidad , PorcinosRESUMEN
BACKGROUND: The differentiation of focal pancreatitis and pancreatic adenocarcinoma is problematic and often resolved only by pancreaticoduodenectomy. EUS is the most sensitive imaging modality for both conditions, yet ultrasonic criteria for distinguishing the two have not been described and differentiation remains difficult. The aims of this study were to develop a self-learning computer program that can analyze EUS images and differentiate malignancy from pancreatitis, and to compare results obtained with this system with EUS interpretation by experienced endosonographers. METHODS: Twenty-one patients with pancreatic cancer and 14 with focal pancreatitis were included. The diagnosis was confirmed histologically in all cases and each patient had undergone EUS. A single EUS image from each procedure was used for computer analysis. The results were compared with the EUS diagnosis reported at the actual procedure as well that of an endosonographer who reviewed videotapes of the procedures. RESULTS: The software program differentiated focal pancreatitis from malignancy with a maximal 89% accuracy. With sensitivity set at 100% for malignancy, the program was 50% specific and accuracy was 80%. Sensitivity and accuracy of the endosonographer's impression at the time of EUS were, respectively, 89% and 85%. A sensitivity of 73% and accuracy of 83% were achieved with blinded interpretation of EUS videotapes. CONCLUSIONS: Analysis of EUS images with computer software programs is feasible and compares favorably with human interpretation. The application of this technology to EUS and other imaging scenarios could be a useful adjunct to diagnostic endoscopy and warrants further investigation.
Asunto(s)
Endosonografía , Redes Neurales de la Computación , Neoplasias Pancreáticas/diagnóstico por imagen , Pancreatitis/diagnóstico por imagen , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/patología , Humanos , Neoplasias Pancreáticas/patología , Pancreatitis/patología , Sensibilidad y EspecificidadRESUMEN
The cases of two fraternal sisters with symptomatic biliary obstruction due to adenomas of the ampulla of Vater are reported. Both sisters had autosomal dominant adult polycystic kidney disease. There are no previous reports of a familial occurrence of ampullary adenomas in the absence of familial adenomatous polyposis, nor has an association between autosomal dominant polycystic kidney disease and ampullary adenoma been described. The coexistence of both disorders in these sisters raises the possibility of a genetic link between autosomal dominant polycystic kidney disease and ampullary adenoma.