How to Distinguish Idiopathic Achalasia from Pseudoachalasia?

Achalasia is a disorder characterized by insufficient relaxation of the lower esophageal sphincter and absent peristalsis. It is usually primary (idiopathic) achalasia, but it can also be secondary achalasia (pseudoachalasia). With a review of the literature, epidemiological data was gathered on achalasia in this paper, and followed up with presented etiopathogenetic mechanisms of achalasia. An optimal diagnostic algorithm along with the therapeutic possibilities in achalasia, from endoscopic to surgical methods of therapy, was analyzed. The most common causes of pseudoachalasia and the mechanisms of this disorder are reported. In patients with dysphagia and suspected achalasia, it is important to distinguish idiopathic achalasia from pseudoachalasia, since pseudoachalasia most often occurs due to tumor infiltrations of the lower esophageal sphincter. In this paper, the importance of a timely and accurate diagnosis of pseudoachalasia in relation to idiopathic achalasia was shown.

Bile duct diameter changes after laparoscopic cholecystectomy: a magnetic resonance cholangiopancreatography prospective study.

AIM: To assess the intrahepatic and extrahepatic bile duct diameter dilatation after laparoscopic cholecystectomy with magnetic resonance cholangiopancreatography. METHODS: Forty-eight patients (35 women, mean age 54.58±11.83 years) underwent laparoscopic cholecystectomy because of gallstones. The intrahepatic and extrahepatic bile ducts were measured before and three and six months after cholecystectomy. The diameter was measured in the anteroposterior and laterolateral direction at 14 points. RESULTS: When compared with the preoperative diameter, the common bile duct diameter at the proximal part was significantly wider three months (P=0.006) and six months (P=0.0001) after cholecystectomy; the common hepatic duct was significantly wider three months (P=0.001) and six months (P=0.003) after cholecystectomy; the right and left hepatic bile ducts were significantly wider six months after cholecystectomy (P<0.0001, P=0.01, respectively); and the segmental intrahepatic bile ducts in both hepatic lobes were significantly wider three months (P<0.0001) and six months after cholecystectomy (P<0.0001). CONCLUSION: This study showed that significant post-cholecystectomy dilatation occurred only at certain points and not along the whole extrahepatic bile duct. We also found a significant dilatation of the main intrahepatic and segmental intrahepatic bile ducts.

HERBALIFE® ASSOCIATED SEVERE HEPATOTOXICITY IN A PREVIOUSLY HEALTHY WOMAN.

Lately there has been an increased consumption of herbal preparations, distributed as nutritional supplements, often claimed to be 'natural' and harmless. However, as their use is not subjected to strict pre-marketing testing and regulations, their ingredients are not clearly defined and there is no quality control or proof of their effectiveness and safety. A growing body of references accentuate their harmful effects, in particular hepatotoxicity, which varies from minimal hepatogram changes to fulminant hepatitis requiring liver transplantation. This case report describes liver damage that was highly suspected to originate from Herbalife® products consumption. We excluded alcohol, viral, metabolic, autoimmune and neoplastic causes of liver lesions, as well as vascular liver disease, but we noticed a connection between the use of Herbalife® products and liver damage. The exact mechanism of liver damage in our patient was not determined. After removing the Herbalife® products, liver damage resolved and there was no need to perform liver biopsy. Taking into consideration the growing consumption of herbal products and their potential harmfulness, we consider that more strict regulations of their production process and sale are necessary, including exact identification of active substances with a list of ingredients, toxicologic testing and obligatory side effect report.

Gastroesophageal variceal bleeding - An overview of current treatment options.

Gastroesophageal variceal hemorrhage is the most important clinical event that results from portal hypertension. It is a lifethreatening condition that demands rapid and efficient treatment. The first step in bleeding control is hemodynamic stabilization and pharmacological treatment, which includes administration of vasoactive drugs and short-term antibiotic prophylaxis. After initial hemodynamic stabilization, endoscopic therapy should be performed. The first choice of endoscopic treatment for esophageal bleeding is endoscopic variceal ligation (EVL), or endoscopic injection sclerotherapy (EIS) if EVL cannot be performed. Several rescue therapies, such as application of balloon tamponade, a selfexpandable metal stent (SEMS), or a transjugular intrahepatic portosystemic shunt (TIPS), are available in cases of resistant variceal bleeding that cannot be controlled with endoscopic therapies. Gastric varices have a lower incidence than esophageal varices, but bleeding from gastric varices is associated with higher mortality and morbidity rates. The first-line treatment, as with esophageal variceal bleeding, is stabilization of the patient. After that, control of bleeding can be attempted. Optimal management of gastric variceal bleeding is not yet standardized due to diverse underlying pathologies and the lack of large, randomized controlled trials. Among endoscopic techniques, endoscopic variceal obturation (EVO) has been acknowledged as reliable. Among rescue therapies, balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices and TIPS are the most common techniques.

What is the Right Therapeutic Approach to Biliary Choledochal Cyst?

We report a case of biliary cyst type II which, independently of its a priori benign nature, caused numerous complications such as recurrent cholangitis and pancreatitis, as well as subsequent hepatic fibrosis and the potential danger of choledochocele perforation. Although they are benign, biliary/choledochal cysts can cause numerous disorders such as cholestasis, leading to cholangitis and pancreatitis and biliary sepsis, and due to chronic inflammation of the biliary system even cholangiocarcinogenesis. Our findings showed that sometimes this type of biliary cyst (according to the available literature the rarest and most benign type), as well as type I cyst, should undergo timely radical excision. In our patient, timely choledochocele resection would have certainly contributed to the reduction of subsequent complications, as well as to obviating repeated invasive diagnostic and surgical procedures.

Laparoscopic Treatment of Morgagni Hernia: Report of Three Cases.

We report on three cases of diaphragmatic (Morgagni) hernia with different clinical presentation. It is important to consider the possibility of this rare but potentially very dangerous condition in patients with respiratory problems and pain in the upper abdomen. Before laparoscopy, two different approaches were used in diaphragmatic hernia operations (abdominal and thoracic approach). Laparoscopy has brought significant changes in the treatment of diaphragmatic hernia. It is important to stress that laparoscopic diaphragmatic surgical therapy uses stronger mesh than the mesh used to repair an inguinal hernia.