[Hemostatic embolization of hepatocellular carcinoma complicated by hemoperitoneum. Apropos of 2 cases and review of the literature]. / Embolisation hemostatique de carcinome hepatocellulaire complique D'hemoperitoine. A propos de deux cas et revue de la littérature.

Rupture of hepatocellular carcinoma is a severe complication that occurs in about 10% of patients. It may occur as a terminal event in patients with advanced disease or it may be the first presentation in a healthy individual. Various treatment options have been proposed, which include conservative treatment, transarterial embolization and operative hemostasis or liver resection. We report intraperitoneal hemorrhage and hypovolemia in two patients with spontaneous rupture of an hepatocellular carcinoma treated successfully by transarterial hepatic embolization. On follow-up, these patients died 7 and 8 months after this treatment respectively.

[Endoscopic evaluation of chronic human immunodeficiency virus-related diarrhea]. / La place de l'endoscopie dans le diagnostic etiologique des diarrhées chroniques des sidéens.

Chronic diarrhea is an important clinical problem in patients infected with HIV. Data assessing the diagnostic yield of upper and lower endoscopy are limited. We reported 10 cases of HIV-infected patient referred to our hospital for chronic diarrhea from March 1995 to June 1999. 60% of the pathogens were identified obviously by stool studies. Cryptosporidium and Mycobacterium avium intracellulare (MAI) were the most common organisms. In this study, endoscopy identified 2 additional cases of MAI and one of 5 cryptosporidia detected in stool. Immunologic test identified a CMV infection in one case. Stool tests and endoscopy identified obviously 80% of the pathogens. Most investigators and us agree that stool studies should be the first diagnostic test. In patients with negative stool studies, lower endoscopy is more cost-effective than upper endoscopy and indicated as an initial exam.

Endoscopic ultrasonographic diagnosis of pancreatic cancer complicating chronic pancreatitis.

BACKGROUND AND STUDY AIMS: Pancreatic cancer is a rare complication of chronic pancreatitis (CP), and its diagnosis remains difficult. The present study attempted to evaluate the ability of endoscopic ultrasonography (EUS) to diagnose pancreatic masses associated with CP and provide evidence of malignancy in patients with a pancreatic mass on EUS. PATIENTS AND METHODS: Between 1991 and 1994, EUS examinations yielded a diagnosis of CP in 85 patients at our institution. Forty patients had early CP, 18 had pancreatic pseudocysts complicating CP, and 27 had advanced chronic pancreatitis - five of whom were considered as presenting pancreatic cancer associated with CP. RESULTS: The five patients studied had jaundice, weight loss, and calcifications visible on plain abdominal films. Three of them had histological confirmation of pancreatic carcinoma. The pancreatic carcinomas were hypoechoic masses of 20-35 mm, with an irregular, rounded shape. Calcifications were limited to the periphery of the hypoechoic masses. Two patients had negative EUS-guided cytological punctures, and are still alive two years later. They were considered as false-positive cases. EUS showed a hypoechoic mass with peripheral calcifications in one of these false-positive patients, with a large central calcification in the other case. The overall sensitivity of EUS for the diagnosis of pancreatic carcinoma was 100%, but the positive predictive value was 60%. CONCLUSION: EUS is highly sensitive in detecting abnormal masses in cases of CP, but the positive predictive value of the diagnosis of pancreatic cancer seems to be weak.

Management of clinically relevant bleeding following endoscopic sphincterotomy.

We report here on our experience of clinically relevant bleeding after endoscopic sphincterotomy (ES). Relevant bleeding was defined by the occurrence of (a) hematemesis or melena and (b) at least a two-point drop in hemoglobin, with no other bleeding source on endoscopy. These two criteria were met in 16 patients between 1983 and 1992. They represented 0.65% of all ES procedures performed during this period. Bleeding occurred immediately after ES in five cases, and was delayed in 11 cases from one to eight days (mean two days). Patients were retrospectively classified into three groups according to the severity of bleeding and subsequent clinical management. In six cases (group 1), bleeding developed slowly without shock and stopped spontaneously. In five cases (group 2), bleeding developed rapidly with melena and a drop in hemoglobin, but without shock. These patients were successfully managed with sclerotherapy without any further complications. The five patients in Group 3 had brisk bleeding with hematemesis and shock. Endoscopic hemostasis could not be performed; emergency arteriography disclosed active bleeding in four patients, and embolization of the gastroduodenal artery was performed. Bleeding stopped in all patients. Billroth II anastomosis appeared to be the only factor associated with an increased risk of clinically relevant bleeding. It was possible to control bleeding following ES using endoscopic or angiographic hemostasis, surgery being avoided in all cases.