Magnetic resonance cholangiopancreatography in cystic lesions of the pancreas.

There are few reports about magnetic resonance cholangiopancreatography (MRCP) in cystic lesions of the pancreas (KLP). For this reason, we have undertaken a prospective study evaluating the diagnostic efficiency of MRCP as compared with ultrasonography. Twenty-four patients with KLP were examined with magnetic resonance imaging (MRI), and standard and cholangiopancreatography. There were seven cases of cysts associated with acute pancreatitis, 11 patients with KLP and chronic calcifying pancreatitis, five cases of cystic neoplasms of the pancreas, and one polycystic disease of the gland. All cases were first submitted to ultrasonography, which failed to diagnose only a case of cyst associated with chronic pancreatitis depicted by MRCP. We used a GE Signa Horizon 1.5-T system (20 examinations) and a Siemens Magneton Plus 1.5-T machine (four examinations). Eleven patients were operated on. In all cases, it was possible to identify the cysts, the main pancreatic duct and the biliary tree, and verify the relationship of the cyst with neighboring organs. Communication of the cyst with the main pancreatic duct was described in five instances, but we cannot be sure that MRCP would have depicted all cyst-duct communications. The MRI and MRCP images were confirmed by surgery in the 11 operated-on cases. The diagnosis of duct alterations and small pancreatic stones in initial cases of chronic calcifying pancreatitis may be problematic. Clinical findings are very important data to be considered in the differential diagnosis of KLP. Together with the clinical data, MRCP is a very important technique in the diagnostic and therapeutic decision making of KLP. Standard magnetic resonance is advisable as part of the examination in all cases. MRCP is not invasive, is reliable if one knows its limitations, and the patient can return at once to his activities. It allows the analysis of many variables in one examination, contributing to better therapy.

Omeprazole, clarithromycin and furazolidone for the eradication of Helicobacter pylori in patients with duodenal ulcer.

AIM: To evaluate the efficacy of omeprazole plus clarithromycin and furazolidone in Helicobacter pylori eradication and duodenal ulcer healing in Brazilian patients. METHODS: Forty H. pylori-positive patients with duodenal ulcer were randomized to receive 20 mg omeprazole o.m. or b.d. for 1 month plus 500 mg clarithromycin (b.d. ) and 200 mg furazolidone (b.d.) for 1 week. RESULTS: Three months after the end of the treatment the eradication rates were 90% by intention-to-treat analysis, and 97% by per protocol analysis. Mild side-effects were observed in 25 patients, none of whom abandoned the protocol. No difference was observed between the 20 mg and 40 mg omeprazole daily doses. Cure or significant improvement of the symptoms and of the histological alterations were observed after H. pylori eradication. CONCLUSION: Our results demonstrate that clarithromycin and furazolidone in combination with omeprazole are a good alternative for H. pylori eradication in Brazilian patients with duodenal ulcer.

Study of the liver changes occurring in preeclampsia and their possible pathogenetic connection with acute fatty liver of pregnancy.

OBJECTIVE: The objective of the present study was to investigate liver involvement in preeclampsia on the basis of clinical, laboratory, and histological data and to detect a possible connection with fatty liver of pregnancy by the determination of microvesicular fatty infiltration of the liver. METHODS: The authors studied the liver changes in 10 patients with preeclampsia, observing the clinical and laboratory alterations, the macroscopic liver surface features by laparoscopy, and the presence of microvesicular fatty infiltration by specific lipid staining of hepatic tissue collected by needle biopsy. RESULTS: Macroscopy of the liver surface disclosed some degree of subcapsular liver hemorrhage in all cases; however, the hemorrhage was not related to the clinical and histological severity of the disease. Microvesicular fat droplets were observed in all patients, and the intensity of the fat deposition was not related to pressor levels, laboratory alterations, or the evolution of preeclampsia. CONCLUSIONS: The presence of fatty liver infiltration in all patients studied supports the idea that preeclampsia and acute fatty liver of pregnancy could be components of the same pathologic spectrum, with a probable, but still unproved, pathogenetic connection. The deficiency of the long chain 3-hydroxyacyl-coenzyme A dehydrogenase activity may be the determining factor in the evolution of the disease.

The use of ethanol injection under endoscopic control to palliate dysphagia caused by esophagogastric cancer.

Nine patients with dysphagia caused by unresectable tumors of the esophagus and cardia (eight with squamous-cell carcinomas and one with adenocarcinoma) were treated with absolute (95 g/l) alcohol mixed with 0.5% methylene blue. Total volumes ranging from 16 to 41 ml were injected endoscopically during sessions separated at 5-day intervals. The results were evaluated by endoscopic and radiological follow-up, as well as clinically, according to Bown's dysphagia score. Treatment had to be stopped in one patient with a preexisting esophagobronchial fistula. In the remaining eight patients, the mean dysphagia score decreased from 3.4 before treatment to 1.2 after treatment. After treatment, all patients were able to swallow a solid or semisolid diet. Treatment was repeated when dysphagia recurred, with a mean interval of 31.5 days between treatments. No complications were encountered. In our view, the preliminary results using this simple and inexpensive technique warrant comparative trials with other methods of palliation.

Treatment of granular cell tumor of the esophagus by endoscopic injection of dehydrated alcohol.

Granular cell tumor of the esophagus (GCTE) is a rare and mostly benign neoplasm. Its etiology is unknown and its histogenesis is uncertain. It is usually an incidental finding, detected during esophagogastroduodenoscopy. In symptomatic cases, or when the lesions are more than 1 cm in diameter, the treatment of choice has been local resection. Asymptomatic patients or tumors smaller than 1 cm are followed endoscopically. We describe a case of GCTE successfully treated by endoscopic injection of dehydrated ethyl alcohol. To our knowledge, it is the first time that such a tumor was treated by this accessible and low-cost technique.

[Lithotripsy of gallbladder calculi with extracorporeal shockwaves]. / Litotripsia de cálculos vesiculares por ondas de choque extra-corpóreas.

Two hundred and sixty two patients with gallbladder stones were prospectively evaluated at the Biliary Lithiasis Treatment Unit of the Mater Dei Hospital, Belo Horizonte, MG., and 45 (17.5%) were selected for extracorporal shock wave lithotripsy (ECSWL). From these, 32 were submitted to the procedure. One stone was present in 30 patients, 2 stones in another and 1 patient had 3 stones. The mean diameter was 14.7 mm ranging from 8 to 28 mm. ECSWL was preceded by 1 week course of ursodeoxycholic acid (8 to 10 mg/dk/day) and this medication was continued after the procedure. ECSWL was done with the Lithosthar-Plus apparatus (Siemens). Meperidine (up to 100 mg) IM and pirazolene IV was given when necessary. The intensity of the shock waves was gradually increased to a maximum (9 bar) whenever tolerated. The treatment was well succeeded in 22 cases (71%) with pulverization in 12 (38.7%). In 9 patients (29%) remaining fragments were greater than 4 mm. From these, 3 were submitted to a second session of ECSWL. In 1 patient the stone could not be properly positioned for lithotripsy. The mean number of shock waves was 2,591, ranging from 801 to 4,411. The mean duration of the sessions was 80 min, ranging from 45 to 150 min. In 3 patients, a complete disappearance of fragments was observed in intervals of 1 to 6 months after the procedure. One patient had severe pain during ECSWL and developed acute cholecystitis. One patient had sinus bradycardia. One patient with total stone pulverization, become jaundiced 1 month after ECSWL and a gallbladder carcinoma was found at surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiology and etiology of chronic pancreatitis in Brazil: a tale of two cities.

We observed 797 consecutive cases of chronic pancreatitis from 1963 to 1987 in the cities of Belo Horizonte and São Paulo. Alcoholism was the main etiological agent, responsible for 714 cases (89.6%). Chronic calcifying pancreatitis from different etiologies, alcohol, idiopathic, nutritional, and familial, was the most important form of chronic pancreatitis, with 786 cases (98.6%). Only three cases of chronic obstructive pancreatitis were diagnosed. Eight cases of chronic pancreatitis, anatomicopathologically studied, have not showed the typical pancreatic changes of either chronic calcifying pancreatitis or of obstructive pancreatitis and were impossible to classify according to the 1984 Marseilles' classification.

[Prospective study comparing the results obtained by liver puncture biopsy with Chiba fine needle and Menghini needle in some tumors of the liver]. / Estudo prospectivo comparando os resultados obtidos por punção biopsia hepática com agulha fina (Chiba) e de Menghini em alguns tumores do fígado.

Seventy-eight consecutive patients (mean age 59 years) have been submitted to concomitant liver biopsy with Menghini and Chiba needles. The same place in the liver was reached by both needles. In 54 cases there was a clinical suspicion of malignancy and in 24 patients biopsy was indicated by other reasons. In 60 cases the biopsies were oriented by laparoscopy. Comparing the results attained by Menghini needle ("gold standard") and the results of the cytologic study of the material obtained with Chiba needle, the last method has proved to be sensible (92.7%), specific (97.3%) and reliable (accuracy = 94.9%).

Etiology of chronic calcifying pancreatitis in Brazil: a report of 329 consecutive cases.

The authors observed 329 consecutive cases of chronic calcifying pancreatitis (CCP) from January 1963 to January 1986. Alcoholism was the etiological agent in 282 cases (86%). In 34 patients (10%) no cause was detectable (idiopathic). Malnutrition was responsible for 10 cases (3%) and chronic familial pancreatitis was diagnosed in 3 cases (0.9%). The mean age at the apparent onset of symptoms was 36.5 +/- 10.5 for the alcoholics, 22.6 +/- 15.4 in the idiopathic cases and 7.3 +/- 3.0 for the nutritional etiology patients. Mean age differences are statistically significant for the 3 groups. Pancreatic calcifications were found in 224 alcohol-induced cases (79%), in 32 idiopathic cases (94%), in 8 patients with malnutrition (80%) and in one patient with familial pancreatitis (33%). All cases of nutritional etiology presented severe protein-caloric deficiencies with edema, and none complained of pain, but 9 had pancreatic insufficiency. Mean daily ethanol intake for the alcohol-addicted patients was 396.6 +/- 286 g (range 80-1664 g) with the onset of alcoholism at 19.1 +/- 6.8 yr old and 20.8 +/- 8.3 (4-44) yr of alcohol indulgence. Pancreatic carcinoma developed in 7 cases. Six cases of chronic pancreatitis were seen among relatives in the group with CCP of alcoholic etiology.

Pancreatic steatorrhea: action of a total lyophilized pancreas preparation: an "in vitro" and "in vivo" study.

A total lyophilized pig pancreas (TLP) preparation was assayed "in vitro" and "in vivo". Lipase activity of the four lots studied was 6.180 +/- 1.122 IU by gram of the commercial product. There was no free trypsin detectable in the preparation. Fifteen pancreatic exocrine insufficiency patients were studied in a period of four weeks. Adult patients received from 35.500 to 35.776 IU of lipase contained in TLP preparation by meal. All patients had their steatorrhea reduced, or normalized, stool weight reduced and body weight increased. There is not an obligatory relation between stool fat loss and stool weight. Steatorrhea decreased at least during the 14 first days of treatment before reaching a stable level. This long delay before reaching a maximum effect deserves to be known: to test the efficiency of a pancreatic extract, the treatment must be given at least two weeks before estimating its results on fecal fat excretion.

Evaluation of the surgical treatment of chronic calcifying pancreatitis.

In the last 20 years, we have observed 264 instances of CCP. Of these, 136 (50.5 per cent) had 171 surgical procedures. Pancreatic calcifications were present in 83.1 per cent of the patients. One hundred and twenty-one were alcoholics (88.9 per cent) and 15 (11.0 per cent) abstained from alcohol. The surgical indications involved clinical uncontrollable pain and organic complications of the disease. The operations performed consisted of 62 wide side to side pancreaticojejunostomies, with loop excluded in Roux-en-Y, 40 pancreatectomies and 69 other operations. The choice of operation depended upon the analysis of each patient. The postoperative period of observation varied from two to 198 months, the average being 56.9 +/- 49.1 months. Thirty-five reoperations were performed for persistence or relapse of pain or the appearance of complications. Immediate post-operative complications and deaths occurred in 44 (25.7 per cent) and in six patients (3.5 per cent), respectively, considering the 71 operations performed. A satisfactory pain relief was evidenced in 61.0 per cent of the patients and total mortality reached 42.6 per cent. When the patients who underwent pancreaticojejunostomy, pancreatectomy and other operations were compared, no significant statistical difference was noticed with regard to the incidence of immediate post-operative complications and deaths, pain relief, appearance of diabetes or steatorrhea and mortality. There was also no significant difference as to the mortality among the alcoholic CCP, calcified or not, and idiopathic CCP (all calcified). On the other hand, the difference was statistically significant concerning the reoperation incidence in the group of patients who underwent the three types of operations mentioned. The longest survival time after pancreaticojejunostomy, pancreatectomy and other operations was 192, 137 and 198 months, respectively. The mean age at the time of death was 44.5 +/- 10.0 years, significantly inferior to the life expectation of the Brazilian male, which is 62 years. The mortality was higher in the first five postoperative years, corresponding to 77.6 per cent of the over-all mortality. There was no significant difference of survival time among the groups of patients undergoing the different types of operations. CCP is an extremely serious disease, progressive in spite of adequate treatment, sensibly diminishing the expectation and quality of lives of those with the condition, often interfering with the activity and productivity of the patient.(ABSTRACT TRUNCATED AT 400 WORDS)

[Concomitance of hepatic lesions with chronic calcifying pancreatitis in the alcoholic. Study of 60 cases]. / Concomitância de lesões hepáticas com pancreatite crônica calcificante do alcoólatra. Estudo de 60 casos.

Sixty patients with chronic calcifying pancreatitis (CCP) of alcoholic etiology have been submitted to liver biopsy: in 44 cases the fragment was obtained during surgery, in four cases under laparoscopy, in five during necropsy, in two blind percutaneous biopsy and both surgical and laparoscopic in two cases. Cirrhosis was demonstrated in eight patients (13,3%). The authors emphasises the necessity in patients with alcoholic CCP.

[Transparieto-hepatic cholangiography with the Chiba needle. Experience in 100 cases]. / Colangiografia transparieto-hepática com agulha de Chiba. Experiência em 100 casos.

One-hundred cases submitted to percutaneous transhepatic cholangiography (PTC) with Chiba's needle were studied. Success rate was 93%, with 100% success in patients with dilated ducts and 78.8% in those with normal ducts. One false-positive result was noticed due to air injection into bile duct in the beginning of the procedure. Complications were seen in 8 cases, without fatalities ascribed to the PTC itself, nor emergency laparotomy was necessary in these cases.

[AW23 and AW24 associated with chronic calcifying pancreatitis of alcoholic origin (author's transl)]. / Associação dos antígenos de histocompatibidade AW23 e AW24 com pancreatite crônica calcificante de origem alcoólica.

Determinations of histocompatibility antigens of A and B loci was undertaken in 22 white male patients with chronic calcifying pancreatitis (CCP) of alcoholic etiology and compared to 100 controls. Results were analysed by the kappa2 test with Yates correction. HLA--AW23 and AW24 were significantly more prevalent in patients than in controls and HLA-B8 was absent in all CCP cases. Although the small number of cases is insufficient to allow any definite conclusion, the obtained data suggests the presence of a genetic predisposition to this disease.

[Chronic calcifying pancreatitis in Brazil: analysis of 92 cases (authors transl)]. / Chronische kalzifizierende Pankreatitis in Brasilien -- Eine Analyse von 92 Fällen

The analysis of 92 proved cases of chronic calcifying pancreatitis showed that 82 were males and 10 were females. Seventy-five out of the 92 patients were chronic alcoholics with a mean age of 38.2 years at the onset of symptoms and with a predominance of males over females (72:3). For the 17 non-alcoholic patients the mean age at the onset was 26.4 years, with almost the same number of males and females (10:7). The differences in age and sex suggest that different factors are responsible for the pathogenesis of the disease. Clinical, surgical and anatomical features of chronic calcifying pancreatitis are discussed. The incidence of pancreatic carcinoma in our patients is higher than in the general population.