[Prognosis and prognostic factors of hemorrhage by rupture of varices in cirrhotic patients in the era of endoscopic sclerotherapy]. / Pronostic et facteurs pronostiques de l'hémorragie par rupture de varice chez le cirrhotique à l'ère de la sclérose endoscopique.

The aim of this study was to evaluate the prognosis and the determinants of survival in cirrhotics presenting with variceal bleeding. One hundred and ninety one consecutive patients with cirrhosis (alcoholic 93 percent) were enrolled between 1983 and 1988. Treatment was principally but not exclusively based on early endoscopic sclerotherapy. At admission all patients were classified according to Child-Pugh's classification (class A = 16 percent; class B = 53 percent; class C = 31 percent). The rebleeding rates at 48 hours and for the entire hospitalisation were 11 and 30 percent respectively. Actuarial survival rates were 45, 40, and 37 percent at 12, 18, and 36 months, respectively. Prognostic factors, as determined by uni- and multivariate analysis (Cox model), corresponded to Child-Pugh's score, to the five components, and the occurrence of early bleeding recurrence. This study also showed that: i) the role of Child-Pugh's classification on long-term prognosis is determined during the 3 months following index bleeding; ii) early rebleeding is a significant prognostic factor, particularly in Child-Pugh's class B patients; iii) there are few indicators of early rebleeding (serum albumin level, presence of gastric varices at initial endoscopy). Prognosis of variceal bleeding is still severe in cirrhosis but efforts made to prevent early bleeding recurrence seem to be fully justified.

Scintigraphic assessment of indium-111-labeled granulocyte splenic pooling: a new approach to inflammatory bowel disease activity.

We have conducted a prospective study into the sensitivity and the specificity of the fall in splenic activity (FSA) as an index of activity in inflammatory bowel disease (IBD). FSA was measured on scintiscans obtained at 3 and 24 hr postinjection of indium-111-labeled granulocytes. One hundred and twenty-two scans were acquired in 96 patients who were divided into six groups: Gr. I = normal volunteers (n = 10); Gr. II = inflammatory rheumatism (n = 10); Gr. III = abscesses (n = 17); Gr. IV = ulcerative colitis (UC: n = 23); Gr. V = colonic Crohn's disease (CCD: n = 22); and Gr. VI = ileal Crohn's disease (ICD: n = 14). FSA for Groups I and II was constantly below 10%, but it was increased in the other four groups (abscesses: 39% +/- 12%; UC: 35% +/- 13.5%; CCD: 23.7% +/- 14.7%; ICD: 21.5% +/- 11.7%). There was a significant correlation between fecal excretion of 111In (FEI) and FSA in patients with IBD (UC: r = 0.71, p less than 0.001; CCD: r = 0.74, p less than 0.001; ICD: r = 0.43, p less than 0.001). FSA was followed in 16 patients with IBD after medical treatment and there was a significant correlation between variations in FSA and in FEI (r = 0.879, p less than 0.001). FSA is a very sensitive although nonspecific index of disease activity in IBD and may replace FEI in the assessment of IBD activity.

Pseudoaneurysms and bleeding pseudocysts in chronic pancreatitis: radiological findings and contribution to diagnosis in 8 cases.

Pseudoaneurysms and bleeding pseudocysts are rare but life-threatening complications of chronic pancreatitis. This report summarizes our experience in 8 cases collected from among 250 patients admitted for chronic pancreatitis. We describe the radiological findings of nine vascular lesions and especially emphasize the contribution of recent radiological imaging, ultrasound and computed tomography scanning in establishing the diagnosis of vascular complication. We also report a case of successful embolization of a splenic pseudoaneurysm that ruptured into the colon.

[Chemotherapy combined with Lipiodol. In vitro study of the kinetics of release of adriamycin]. / Chimiothérapie couplée au Lipiodol. Etude in vitro de la cinétique de libération de l'adriamycine.

Intra-arterial injection of lipiodol-adriamycin mixtures are commonly used in the treatment of hepatic tumors based on the progressive release of adriamycin. This study was undertaken to assess, in vitro, the influence of mixture formulations on the adriamycin release pattern. Eight mixtures containing 10 mg of adriamycin were tested. Adriamycin was tested in solution (mixture A) in suspension (mixture B), or in emulsions with Hexabrix 320 (mixtures C to F). Ratios between Hexabrix and lipiodol volumes were 2/1, 1/1, 1/2, and 1/4 for emulsions C, D, E, and F, respectively. Emulsions G and H corresponded to emulsions E and F, with Arlacel A as emulsifying agent. All mixtures were prepared in triplicate and added with water. Samples of 200 microliters were taken from the aqueous phase after 10, 20, 30 min, 1, 2, 4, 8, 24, 48, 72, and 120 h for adriamycin dosage. Lipiodol-adriamycin mixture formulation significantly influenced the release pattern of adriamycin. Three formulations (suspension, emulsions 2/1 and 1/4) induced the most progressive release of adriamycin from lipiodol. This release was dramatically retarded by the addition of an emulsifying agent.

[Antral vascular ectasia and scleroderma. Endoscopic, radiologic and anatomopathologic aspects of an uncommon association]. / Ectasie vasculaire antrale et sclérodermie. Aspects endoscopiques, radiologiques et anatomopathologiques d'une association originale.

Diffuse gastric antral vascular ectasia (GAVE) is a new disease entity corresponding to peculiar acquired vascular malformations. In 1984 Jabbari et al. coined the term "Watermelon Stomach" for this lesion. We report here in a new case particular by its association with systemic sclerosis in a 66 year-old female. The diagnosis of GAVE was suggested upon endoscopic and angiographic findings. Atrophic fundic gastritis associated with achlorhydria and hypergastrinemia was also noted. Antrectomy was performed with success. Pathologic examination and morphometric analysis of the antrum specimen revealed the characteristic features of GAVE: 1) increase of the mean cross sectional area of mucosal vessel lumen and increase of the mean percentage of specimen area occupied by vessels; 2) presence of intravascular fibrin thrombi and 3) fibromuscular hyperplasia of the lamina propria.

[Surgical treatment of chronic pancreatitis. Indications and results. An experience of 246 cases]. / Traitement chirurgical de la pancréatite chronique. Indications et résultats--Expérience de 246 cas.

Between 1972 and 1986, 246 patients, mainly alcoholic, with a mean age of 44 years, underwent a total of 270 laparotomies. Parenchymal resections were carried out in 99 patients and drainage and diversion procedures were carried out in 159. Pain was the principal symptom and led to surgery in 60% of cases; biliary or duodenal obstruction was present in 40 and 23.5% of cases respectively. Operative mortality was 9% for resections and 5.8% for other forms of surgery. In the long term, the best results were obtained in patients in whom a Whipple procedure was performed.

[Diffuse pseudopolyposis of the colon: developmental form or cicatricial of hemorrhagic rectocolitis?]. / La pseudopolypose diffuse du côlon: forme évolutive ou cicatricielle de la rectocolite hémorragique?

The authors report the case of a patient with generalized polyposis associated with ulcerative colitis. The diagnosis of polyposis was made 20 years after the onset of colitis. The patient presented with the unusual clinical manifestations, ie poor general condition and severe denutrition, following a severe relapse of colitis. The mucosal surface of the entire colon, except the rectum, was covered by innumerable polyps, without any macroscopic or microscopic evidence of ulceration. Intestinal protein loss, as assessed by alpha-1-antitrypsin clearance, was very high (470 ml/d). Acute mucosal inflammation, as assessed by histologic study and by 111-Indium-labelled-leukocyte scintigraphy, was also present. The patient responded dramatically to total colectomy with ileorectal anastomosis. Histologically, the polyps were filiform, with a central core, containing vessels and smooth muscle fibers. This observation demonstrates that generalized polyposis, generally considered to be an asymptomatic sequela of ulcerative colitis, can also be associated with severe attacks of colitis.

Hepatic artery injection of I-131-labeled lipiodol. Part I. Biodistribution study results in patients with hepatocellular carcinoma and liver metastases.

Biodistribution of iodine-131-labeled Lipiodol Ultra-Fluide (I-131 LUF) injected into the hepatic artery was studied scintigraphically in 47 patients with hepatocellular carcinoma (n = 23), hepatic metastases (n = 14), or normal livers (n = 10). The investigation was extremely well tolerated. I-131 LUF concentrated mainly in the liver (L) and the lungs (l), with L/L + l activity ratios greater than 75% for all three groups of patients. I-131 LUF distribution was homogeneous in normal livers and heterogeneous in cirrhotic livers. I-131 LUF concentrated in the tumor with a tumorous (T) to nontumorous (NT) activity ratio (T/NT) of 4.3 +/- 3.6 for hepatocellular carcinoma and 2.4 +/- 0.7 for hepatic metastases. The effective half-life of I-131 LUF is more than 4.5 days for the three groups. It was eliminated mainly through the urine. Clearance from tumor is slower than from normal liver, as shown by the increase in T/NT at day 18. Biodistribution did not change in patients who had a second injection, which indicates that there is no saturation phenomenon. The results of this study suggest that LUF may be considered as a potential carrier vehicle for therapeutic agents.

Hepatic artery injection of I-131-labeled lipiodol. Part II. Preliminary results of therapeutic use in patients with hepatocellular carcinoma and liver metastases.

Internal radiation therapy with transarterial injection of iodine-131-labeled iodized oil (Lipiodol Ultra-Fluide [LUF]) was evaluated in 15 patients with hepatocellular carcinoma and eight with hepatic metastases. Five patients with hepatocellular carcinoma received more than one injection. Treatment tolerance was excellent, as assessed clinically and by means of liver function tests. An analgesic effect was noted in the two patients with painful hepatocellular carcinomas. Serum alpha 1-fetoprotein levels dropped rapidly in 11 of the 12 patients with elevated basal values. An average reduction in tumor size of 50% was observed in the nine cases followed up with computed tomography. After 5-12 months of follow-up, six of the 15 patients with hepatocellular carcinoma were alive. Two of them had undergone liver transplantation. Histologic examination of one of the livers, removed 3 months after a third injection, revealed microscopic features highly suggestive of radiation effect in LUF-containing areas. In the group with widespread hepatic metastases, no objective response was noted, except for an analgesic effect in three cases.

[pHmetry and manometry of the esophagus in patients with pain of the angina type and a normal angiography]. / pH-métrie et manométrie de l'oesophage chez des sujets avec douleurs de type angineux et une coronarographie normale.

The role of gastroesophageal reflux and esophageal motility abnormalities in patients with angina-type chest pain and normal coronary angiogram is not clear. The aim of this study was: a) to assess the importance of these two disorders in the same patients, b) to study the diagnostic usefulness of provocation tests, c) to determine final outcome in these patients. Seventeen patients with angina-type chest pain and normal coronary angiograms were studied to determine the diagnostic value of esophageal manometry, postprandial esophageal pH monitoring, provocation tests (methylergometrine stimulation, acid perfusion test) and endoscopy. Baseline esophageal motility was abnormal in 10 patients. Esophageal motility disorders were nonspecific in seven patients. Eight patients had reflux. The mean lower esophageal sphincter pressure was decreased in these patients as compared with normals, and endoscopy showed a high Z line, and/or a large opening of the cardia in 7 of them. Neither conventional manometry nor postprandial esophageal pH monitoring allowed to consider the esophagus as responsible for chest pain. The methylergometrine test was positive in 4 patients (simultaneous occurrence of familiar pain and esophageal dysmotility). Baseline manometric studies did not allow to forecast the response to methylergometrine injection. The acid perfusion test was negative (no symptoms were reproduced) in all patients. After esophageal evaluation, 16 patients were followed for a mean of 26 +/- 9 months. No cardiac disorders appeared, but all patients continued to have pain, and 7 were incapable of working.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcifying pancreatitis of a congenital short pancreas: a case report with successful endoscopic papillotomy.

We report a case of partial pancreatic agenesis in a 25-yr-old man with insulin-dependent diabetes who exhibited abdominal pains in relation to a calcifying chronic pancreatitis. An endoscopic retrograde pancreatography through the accessory papilla revealed an abnormal duct configuration thought to be consistent with an obstruction of the main duct. Ultrasonography and computerized tomography scanning could not identify any pancreatic tissue in the region of the body or tail. Another endoscopic investigation revealed the main papilla in the third part of the duodenum. The ducts of Santorini and Wirsung were identified. Santorini's duct was dilated and contained calculi. Wirsung's duct was nearly normal. The junction between the two ducts was slightly narrowed. After papillotomy of the accessory papilla, the patient's abdominal pains disappeared. This new case of congenital short pancreas is discussed in relation to four other cases reported in the English and French literature.

[Splenogastrorenal shunt in portal hypertension: a little known entity. Study of 6 cases and review of the literature]. / Le shunt spléno-gastro-rénal dans l'hypertension portale: une entité méconnue. Etude de 6 cas et revue de la littérature.

The authors report 6 cases of portal hypertension with gastrorenal shunt. This shunt did not arise from the left gastric vein, but from the splenic vein. Portal hypertension was related to alcoholic cirrhosis in 3 cases, to extensive portal thrombosis in 2 cases, and to nodular regenerative hyperplasia of the liver in one case. A gastrointestinal hemorrhage revealed portal hypertension and the liver disease in the 3 cases of alcoholic cirrhosis and complicated the course of the disease in the other cases. Hemorrhage was either massive and life-threatening or often recurred. It was related to a rupture of fundic varices in all cases. The fundic varices were not associated with esophageal varices in the 3 cases of cirrhosis. The degree of portal hypertension was above 20 mm Hg, as assessed by the portohepatic gradient (one case), or the pressure gradient between a tributary portal system vein and the inferior vena cava during laparotomy (5 cases). Definitive control of hemorrhage could not be achieved by endoscopic variceal sclerotherapy (2 cases) or percutaneous transhepatic embolization (one case). Portacaval shunt or splenectomy was performed in 5 cases. These findings suggest that spontaneous splenogastrorenal shunt is a clinical and hemodynamic entity which requires specific treatment when associated with gastric variceal bleeding.