Intravenous nitroglycerin for prevention of pancreatitis after therapeutic endoscopic retrograde cholangiography: a randomized, double-blind, placebo-controlled multicenter trial.

BACKGROUND AND STUDY AIMS: Several studies have suggested that nitroglycerin promotes pancreatic drainage and thereby helps to prevent pancreatitis occurring after endoscopic retrograde cholangiography (ERC). We performed a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of intravenous nitroglycerin for preventing acute pancreatitis in moderate- to high-risk patients undergoing ERC. PATIENTS AND METHODS: The patients underwent therapeutic ERC for gallstone removal, bile duct stenosis, or sphincter of Oddi dysfunction (SOD). They were randomly allocated to receive an intravenous nitroglycerin bolus of 0.1 mg, then 35 microg/kg per minute intravenously (maximum dose 9 mg) for 6 h, or an identical placebo regimen. Serum amylase and lipase levels were determined before and 24 h after ERC. RESULTS: The study was terminated after the interim analysis. The intention-to-treat population consisted of 208 patients enrolled in 20 centers, of whom 105 received nitroglycerin and 103 placebo therapy. Post-ERC pancreatitis (mild/moderate/severe) occurred in 25 patients, comprising 10 (3/5/2) in the nitroglycerin arm and 15 (5/6/4) in the placebo arm (OR 0.62, 95 % CI 0.26 - 1.45; P = 0.26). Pancreatitis-related hospital stays were similar in the two groups (median 4 days, range 2 - 13 days in the nitroglycerin group; median 5 days, range 2 - 20 days in the placebo group). The incidence of pancreatitis in patients with SOD did not differ between the groups (4/11 in the nitroglycerin arm, and 4/15 in the placebo arm). Adverse events were more frequent in the nitroglycerin group and led to cessation of drug infusion in 10 patients in the nitroglycerin arm and in 2 patients in the placebo arm ( P = 0.019). CONCLUSION: In this study, nitroglycerin offered a limited and clinically nonsignificant benefit for the prevention of post-ERC pancreatitis. Its use did not improve the technical success rate of ERC.

Renal impairment in patients with inflammatory bowel disease: association with aminosalicylate therapy?

BACKGROUND: In recent years, several case reports have been published suggesting an association between the use of 5-aminosalicylic acid (5-ASA) in patients with inflammatory bowel disease (IBD) and the development of chronic tubulo-interstitial nephritis. Apart from lesions associated to 5-ASA treatment, however, it is clear that IBD itself may also induce renal impairment, albeit the frequency is unknown. METHODS: During 1 year, all IBD patients seen at the outpatient clinic of 27 European centres of gastro-enterology were registered and screened for renal impairment controlling for a possible association with 5-ASA therapy. Patients were questioned about their medical and drug history and their IBD disease activity. Renal screening (calculated creatinine clearance) was performed at baseline, after 6 and 12 months. RESULTS: Included patients (n = 1,529) had a mean age of 39 (range 14-98), 56% had Crohn's disease, 42% ulcerative colitis and 2% indeterminate colitis. Half of the patients used 5-ASA during the study period. Decreased creatinine clearance was observed in 34 patients, among them 13 with chronic renal impairment. Comparing patients with and without renal impairment, no difference could be observed in 5-ASA consumption. In contrast, patients with renal impairment were significantly older, had a lower body mass index and showed a higher frequency of male sex, bowel resection and stoma. CONCLUSION: Although the association between 5-ASA therapy and chronic tubulo-interstitial nephritis is clearly described in several case reports, this prospective study came to the reassuring conclusion that renal impairment in IBD patients is not frequently observed and is rarely associated with 5-ASA therapy.

[Absence of subrenal inferior vena cava revealed by rupture of duodenal varices in an adult]. / Absence de veine cave inférieure sous-rénale révélée par une rupture de varices duodénales chez un adulte.

This report concerns a case of absence of caudal inferior vena cava revealed by gastrointestinal bleeding from isolated duodenal varices by an adult. The diagnosis of duodenal varices was performed by ultrasonographic endoscopy. Development of duodenal varices in absence of portal hypertension is uncommon. Involvement of cavo-portal collateral circulation in case of inferior vena cava obstruction is unusual and duodenal varices are still more rarely encountered. Diagnosis was ultimately supported by femoral venous angiography showing the absence of inferior vena cava and a venous return from the right lumbar vein into the portal vein via the duodenal varices. The absence of caudal portion of inferior vena cava is more probably related to neo-natal thrombosis than to a true atresia.

Recent developments in medical therapy of POAG with beta blocking agents.

Since 1987, an entirely computerized open study has been developed in Pr Sole's Ophthalmology Department: the CLERTORE project (Clermont-Tonus-Research). It is a data bank including all the ophthalmic data of hypertensive patients, whether treated or untreated. Every six months, the patients included in the CLERTORE project undergo a clinical ophthalmic examination as well as an automated visual field examination (OCTOPUS 500), an examination of the optic disc (ONHA) and fluorophotometry (FLUOROTRON MASTER). To date, 92 patients have been included in the project. One hundred and eighty-three eyes are examined every six months with a maximal follow-up of 42 months. Because of the numerous criteria of the data base, it is too early to give any statistical results. With a close look at the evolution of the examinations of some of our cases, this preliminary work however allows us to make the three following remarks: In the hypertensive patients, a modification of the papillary pallor is observed without any change in the visual field, C/D ratio and fluorophotometry. The pallor is clearly modified when adrenaline eye drops are given to glaucomatous patients. There is a break of the iridic blood barrier in some hypertensive patients, whether treated or untreated.

[Jejunal secretion of immunoglobulins and secretory component in three patients with primitive humoral immunoglobulin deficiency]. / Sécrétion jéjunale des immunoglobulines et du composant sécrétoire chez trois patients atteints de déficit immunitaire humoral primitif.

Jejunal secretion of albumin, immunoglobulins and secretory component was studied using the segmental perfusion technique with an occluding balloon, in two patients with common variable hypogammaglobulinemia and one patient with selective immunoglobulin A deficiency. Results were compared with those of twenty-two controls previously studied under the same conditions. In all three cases, jejunal secretion rate of immunoglobulin A was nil and secretion rates of albumin and immunoglobulin G were increased as compared to controls. Jejunal secretion rate of immunoglobulin M was increased in the patient with selective immunoglobulin A deficiency, normal in one case of common variable hypogammaglobulinemia and almost nil in the other case. Secretory component was secreted in the jejunal lumen mostly or exclusively under a free form depending on partial or total absence of immunoglobulin A and M. This study allowed to confirm in vivo that secretion of secretory component is independent of the presence of immunoglobulins. Intestinal perfusion might be a useful tool in the investigation of immunological diseases of the intestinal tract.

[Functional and motor study of retrosternal esophageal plasties]. / Etude fonctionnelle et motrice des plasties oesophagiennes rétrosternales.

The stomach may be used for esophageal reconstruction after resection of esophageal cancers. The aim of this study was to assess the motility of retrosternal esophagoplasty (RO) following the Akiyama procedure in 6 men (mean age: 56.7 years), at least two months after surgery by means of two techniques: a) manometry of the transplant with a multilumen perfused catheter in 50 and 40 cm from the incisor teeth including spontaneous (5 min) and poststimulation recordings, b) an isotopic method for assessing the gastric emptying of a meal labelled with 111In for the liquid phase and with 99mTc for the solid phase, compared to 12 volunteers as controls. Baseline pressure was 11.2 +/- 2.4 H2O cm without spontaneous activity. After dry and wet deglutition (5 ml of water), 6 patients showed synchronous rise in pressure, having mean amplitude of 12.7 +/- 2.3 cm H2O and lasting 4.3 +/- 1.2 s. Liquids T1/2 was 16.2 +/- 7.8 min in controls (p less than 0.01) and solids T1/2 was 17.7 +/- 6.4 min vs 61.7 +/- 16.5 min (p less than 0.001). The lack of propagated activity associated with rapid emptying of the meal through the plasty with no discrimination between solids and liquids suggests that RO does not participate actively in digestion.

[Esophageal cancer and endoscopic sclerosis of esophageal varices: a fortuitous association?]. / Cancer oesophagien et sclérose endoscopique des varices oesophagiennes: une association forfuite?

We report the case of 4 male patients, smokers, with alcoholic cirrhosis, mean age 54.7 +/- 6 years, treated by sclerotherapy for bleeding esophageal varices. Variceal eradication was obtained following juxtacardial intravariceal injection of 1.5 p. 100 polidocanol in one case (100 ml), and 0.5 p. 100 polidocanol in 3 cases (90, 240 and 310 ml). Local complications were observed in all patients (ulcers: 3; stenosis: 1). Carcinoma of the lower third of the esophagus was detected 12, 20, 22 and 30 months after esophageal sclerosis. Carcinoma was circular (one case), semicircular (2 cases), and nodular superimposed on Barrett's esophagus (one case). Histologic features included squamous cell carcinoma in 3 cases and adenocarcinoma in one case. Sclerotherapy could lead to the development of carcinoma because of mucosal alterations. However, other high risk factors (age, alcohol-tobacco intoxication, Barrett's esophagus) and different histologic features suggest a causal association. Endoscopic follow-up of patients after esophageal sclerosis could confirm this hypothesis.

Paraneoplastic intestinal pseudo-obstruction as the presenting feature of small-cell lung cancer.

A previously healthy 50-year old man presented with acute small bowel obstruction. No etiology was found at laparotomy. Postoperatively, the patient remained symptomatic with nausea, vomiting and severe constipation. Gastroscopy revealed retained food in the stomach. Gastric emptying of solids and liquids was dramatically decreased at scintigraphy. The colon was dilated on X-ray study. Chest X-ray revealed a pneumopathy and a small-cell lung cancer was discovered at bronchoscopy. The patient died 5 months after onset. Histologic study of the gut showed widespread degeneration of the myenteric plexus with plasma cell infiltration, Schwann cell proliferation and a reduced number of neurons of which many were abnormal. Intestinal pseudo-obstruction can reveal a small-cell lung cancer; the mechanism of neuronal impairment leading to pseudo-obstruction remains unknown, but could be related to the pathophysiology of paraneoplastic syndromes.

[Alpha-methyl-paratyrosine in the treatment of malignant pheochromocytoma]. / L'alpha-méthyl-paratyrosine dans le traitement des phéochromocytomes malins.

Alpha-methyl-paratyrosine (Demser) is a specific inhibitor of tyrosine hydroxylation to dopa. It is administered orally and may be given in combination with symptomatic treatments to reduce the hypersecretion of catecholamines. We report two cases of malignant phaeochromocytoma in which this drug was used. A pharmacological study of the compound is presented, and the literature on its long-term use in the treatment of malignant phaeochromocytoma is reviewed. In our second patient, who received alpha-methyl-paratyrosine for 9 months, a study of changes in differential catecholamine excretion showed that the urinary catecholamines were redistributed, with an increase in the dopamine/norepinephrine ratio. An HPLC study of urinary excretion of catecholamines demonstrated that their levels cannot be significantly increased by excretion of alpha-methyl-paratyrosine or its metabolites.

[Fluorophotometry by instillation. II. Effect of beta-blocker eyedrops in the normal subject]. / Fluorophotométrie par instillation. II: Effet d'un collyre bêta-bloquant chez le sujet normal.

The effects of various drugs on the human aqueous humor flow were studied by the fluorophotometric method of Yablonski (topical fluorescein instillation). The effect of the beta-adrenergic blocker (Timolol) on aqueous humor flow and on intra-ocular pressure has been studied in ten normal eyes on the Fluorotron Master. We found that the acute decrease in intra-ocular pressure was equal to 1.39 +/- 0.44 microliter.min-1 for the Timolol treated eyes, and equal to 2.79 +/- 0.57 microliter.min-1 for the untreated eyes (Placebo). The difference between Timolol and Placebo was statistically significant (Student t-tested, and Wilcoxon W-tested). The fluorophotometric method is superior to the tonographic method by giving a more favorable condition to study the facility of outflow in steady physiological state. Our results are in good agreement with other authors and show Timolol to have little or no effect on the facility of outflow.

[Prenatal echographic diagnosis of iniencephaly. Apropos of a case]. / Diagnostic échographique anténatal de l'iniencéphalie. A propos d'un cas.

Iniencephaly is a rare lethal malformation. It is associated with a defect in the occiput, alterations in the spinal column that are variable and retroflexion of the fetus. Antenatal diagnosis by ultrasound is possible because of the typical appearance: the fetal head is hyperextended, with distortion and shortening of the cervical spine. The occiput can be fused with lower vertebrae. Many associated malformations may be found: polyhydramnios, neurologic, facial and visceral abnormalities.