Risk factors and outcome of community onset Pseudomonas aeruginosa bacteraemia in two Malaysian district specialist hospitals.

INTRODUCTION: Despite the ever-growing number of community onset (CO) Pseudomonas aeruginosa (P. aeruginosa) bacteraemia, there is a dearth of district hospital-based research examining this significant infection, which is associated with high mortality. The objectives of this study were as following: (1) to determine the risk factors of CO P. aeruginosa bacteraemia, (2) to compare the 30-day mortality rate between P. aeruginosa and Escherichia coli bacteraemia and (3) to identify the predictors of 30-day mortality for CO gram negative bacteraemia. METHODS: This is a retrospective case control study in Hospital Seri Manjung and Hospital Teluk Intan, Perak, Malaysia. P. aeruginosa bacteraemia cases that occurred between 1st January 2015 to 31st December 2019 were included, whilst E. coli bacteraemia cases that occurred within the same period were recruited successively until 1:2 case control ratio was achieved. Subjects below 12-year-old and those with polymicrobial bacteraemia were excluded. Demographic, clinical and treatment data were collected using pre-tested data collection forms by trained investigators. RESULTS: A total of 61 patients with P. aeruginosa bacteraemia and 122 patients with E. coli bacteraemia were included. Recent admission in the earlier three months, regular haemodialysis, immunosuppressive therapy in the past 30 days, chronic wound/pressure sore at presentation and indwelling urinary catheter at presentation were identified as independent predictors of CO pseudomonal bacteraemia. Whilst older age was identified as a negative predictor of CO Pseudomonal bacteraemia (all p<0.05). The 30-day mortality rate was 34.4% in subjects with P. aeruginosa bacteraemia and 27.0% in those with E. coli bacteraemia (p=0.302). Predictors of 30-day mortality for community onset gram negative bacteraemia were as follow: older age, underlying solid tumours, neutropaenia at presentation, in-patient mechanical ventilation, and inpatient nasogastric tube insertion. Unexpectedly, receipt of inappropriate empirical antibiotics which was switched later (delayed and non-delayed switching) was identified as the negative predictors of mortality (all p<0.05). CONCLUSION: It is prudent to restrict the usage of empirical anti-pseudomonal antibiotics among individuals at risk as liberal usage of broad-spectrum antibiotics engenders emergence of drug resistant organism, particularly in district setting where community onset pseudomonal bacteraemia remains scarce. Subjects with elevated risk of mortality should receive early escalation of care as per sepsis management guidelines.

Dengue Encephalitis associated with symptomatic hyponatremia due to Syndrome of Inappropriate Antidiuretic Hormone Secretion.

A previously well 21-year-old girl presented to Hospital Teluk Intan, Perak, Malaysia with a short history of fever, vomiting and altered sensorium. She was diagnosed with dengue encephalitis as her dengue NS-1 antigen was positive and her cerebrospinal fluid (CSF) dengue polymerase chain reaction (PCR) was positive with serotype DENV-2. She also had severe hyponatremia due to Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) which caused an episode of seizure. She recovered well with supportive management. SIADH and dengue encephalitis should be considered as one of the differential diagnosis in patients presenting with fever and altered sensorium especially in dengue endemic countries like Malaysia.

Radiofrequency ablation for 110 malignant liver tumours: preliminary results on percutaneous and surgical approaches.

BACKGROUND: Radiofrequency ablation (RFA) has been widely applied for the treatment of hepatocellular carcinoma and liver metastases. The reported mortality and morbidity rates are low. The aim of this study is to evaluate the safety and efficacy of RFA, and compare the results performed percutaneously versus surgically. PATIENTS AND METHODS: From 2003 to 2006, 79 patients with hepatic malignancies (59 hepatocellular carcinoma, 20 liver metastases) with a total of 110 lesions underwent RFA in our centre. Postablation assessment by CT scan was performed in all patients at 1-, 3- and 6-month intervals. Post-procedural complications, recurrence and survival were analysed. RESULTS: The patients' mean age was 60.0 years. In 46.8% of cases, we used a percutaneous approach; in 53.2% of cases, a surgical approach (8.9% laparoscopic; 44.3% open) was used if percutaneous approach was not feasible. The mean tumour size was 2.4 cm. Within the surgical group, 69% of patients received concomitant operative procedures such as cholecystectomy and hepatectomy. No treatment-related mortality was observed. Immediate complications occurred in five patients (6.3%), including gastric serosal burn (n = 1), ground pad superficial skin burn (n = 1), intra-abdominal bleeding (n = 2) and pleural effusion (n = 1). All patients except one attended subsequent follow-up, with a mean period of 16 months. Ablation was considered complete in 82.3% of patients (percutaneous approach 81.1%, surgical approach 83.3%, p = 0.72). Intrahepatic recurrence was observed in 52.3%, the majority of them located away from the RFA site. Extrahepatic recurrences were observed in 16.9% (percutaneous approach 16.7%, surgical approach 17.1%, p = 0.76). The overall one- and two-year survival rate was 93.7% and 74.4% respectively, and no statistically significant difference was observed between the two approaches. CONCLUSION: RFA is a safe and effective procedure for treating patients with malignant liver tumours. No difference in short term outcomes was observed between percutaneous and surgical approaches. A more prolonged follow-up study is required to assess longer-term outcomes.

Dimethyl sulfoxide as an inducer of differentiation in preosteoblast MC3T3-E1 cells.

Osteoblastic differentiation is an essential part of bone formation. Dimethyl sulfoxide (DMSO) is a water miscible solvent that is used extensively for receptor ligands in osteoblast studies. However, little is known about its effects on osteoblastogenic precursor cells. In this study, we have used a murine preosteoblast cell line MC3T3-E1 cells to demonstrate that DMSO effectively induces osteoblastic differentiation of MC3T3-E1 cells via the activation of Runx2 and osterix and is dependent upon the protein kinase C (PKC) pathways. We further demonstrated that prolonged activation of PKC pathways is sufficient to induce osteoblastic differentiation, possibly via the activation of PKD/PKCmu.

A newly discovered verotoxin variant, VT2g, produced by bovine verocytotoxigenic Escherichia coli.

A new verotoxin (VT) variant, designated vt2g, was identified from a bovine strain of verocytotoxigenic Escherichia coli (VTEC) serotype O2:H25. When vt2g was aligned with published sequences of vt2 and vt variants, it exhibited the highest DNA sequence homology with vt2 and vt2c. However, vt2g was not detected by vt2-specific primers and probes, although it was partially neutralized by an antiserum to the VT2A subunit. VT2g was cytotoxic for Vero and HeLa cells and was not activated by mouse intestinal mucus. The vt2g gene was detected in 3 of 409 (0.7%) bovine VTEC strains, including serotypes O2:H25, O2:H45 and Ont:H-.

Polyclonal antibodies to glutathione S-transferase--verotoxin subunit a fusion proteins neutralize verotoxins.

The A1 subunits of verotoxin-1 (VT1) and VT2 genes were cloned into pGEX-4T-2 for the expression of glutathione S-transferase (GST) fusion proteins. The N-terminal and the transmembrane regions of the A1 subunits were excluded from the constructs in order to increase the product yields. Polyclonal anti-VT1A1 and anti-VT2A1 antibodies were produced by immunizing rabbits with GST-VT1A1 and GST-VT2A1 fusion proteins, respectively. The antibodies were tested for their ability to neutralize active toxins from 45 VT-producing Escherichia coli (VTEC) strains. The antibodies had significantly high neutralizing activities against their homologous toxins. The average percentages of neutralization of VT1 by anti-GST-VT1A1 and anti-GST-VT2A1 were 76.7% +/- 7.9% and 3.6% +/- 2.3%, respectively, and those of VT2 were 1.7% +/- 2.3% and 82.5% +/- 13.9%, respectively. VT2 variant toxin was neutralized by anti-GST-VT2A1, with cross neutralization being a possible consequence of sequence homology between VT2 and a VT2 variant. To our knowledge, this is the first report on the production of polyclonal antibodies from GST-VT fusion proteins. The antibodies were shown to exhibit specific toxin neutralizing activities and may be useful for immunological diagnosis of VTEC infections.

Fluoroquinolone resistance among Streptococcus pneumoniae in Hong Kong linked to the Spanish 23F clone.

Serotypes 6A/B, 19F, and 23F accounted for 73% of 140 mucosal isolates of Streptococcus pneumoniae from Hong Kong. In pulsed-field gel electrophoresis analysis, a group of related patterns was shared by 14 of 15 ciprofloxacin-resistant and 12 of 16 ciprofloxacin-susceptible isolates. These strains exhibited capsular switching and were highly similar to the Spanish 23F clone.

Increasing resistance of Streptococcus pneumoniae to fluoroquinolones: results of a Hong Kong multicentre study in 2000.

The MICs of 13 antimicrobial agents including seven fluoroquinolones (ciprofloxacin, levofloxacin, sparfloxacin, grepafloxacin, gatifloxacin, moxifloxacin and clinafloxacin) for Streptococcus pneumoniae isolates obtained from all regions of Hong Kong in the year 2000 were determined by the Etest. Overall, 39.4% of 180 isolates were susceptible to penicillin, 11.7% were intermediate and 48.9% were resistant. The overall prevalence of fluoroquinolone non-susceptibility (levofloxacin MIC > or = 4 mg/L) was 13.3% but increased to 27.3% among the penicillin-resistant isolates. For the fluoroquinolone non-susceptible isolates, within-class cross-resistance was common. For the fluoroquinolone non-susceptible isolates, the median MICs of clinafloxacin, gatifloxacin, moxifloxacin, sparfloxacin and grepafloxacin were, respectively, six-, 24-, 32- 84- and 128-fold higher than those for the susceptible isolates. All fluoroquinolone non-susceptible strains were derived from adults. The prevalence of fluoroquinolone resistance was higher in isolates from older patients (17.1% among those > or = 65 years of age versus 9.1% among those 18-64 years of age, P < 0.001) and from adults with chronic obstructive pulmonary disease (24.6% versus 9.3%, P = 0.01). All fluoroquinolone non-susceptible strains were non-susceptible to penicillin (MIC range 2-4 mg/L), cefotaxime (MIC range 1-4 mg/L) and erythromycin (MIC range 4- > or = 256 mg/L). The fluoroquinolone non-susceptible isolates were genetically related to the Spain(23F)-1 clone when analysed by pulse-field gel electrophoresis and multilocus sequence typing. In conclusion, a rapid increase in the prevalence of fluoroquinolone resistance among S. pneumoniae was found in Hong Kong. Typing analysis suggests that this is due to the pan-regional dissemination of a fluoroquinolone-resistant variant (designated Hong Kong(23F)-1) of the globally distributed Spain(23)F-1 clone.

The prevalence and characterization of verotoxin-producing Escherichia coli isolated from cattle and pigs in an abattoir in Hong Kong.

The aim of the study was to define the prevalence of verotoxin-producing Escherichia coli (VTEC) in cattle and pigs in a Hong Kong abattoir. Faecal and carcass samples collected from 986 cattle and 487 pigs from an abattoir were tested for verotoxin (VT) by PCR and cytotoxicity assays. VTEC was isolated from 415 and 1-8% of cattle faecal and carcass samples and from 2.1 and 0.2% of porcine faecal and carcass samples, respectively. Amongst 409 VTEC isolates from cattle, 9 were serotype O157:H7 and eaeA+. The most prevalent vt genotype among bovine VTEC was vtl+vt2 (73.8%) and in porcine VTEC was vt2e+ (30%). None of the porcine VTEC isolates and 9.3% of the bovine VTEC isolates was eaeA+. The non-O157 serogroup VTEC isolates carrying eaeA and EHEC-hlyA belonged to serogroups O172, O15, O84, O91, O110 and O121. The local dietary preference for pork or chicken (rather than beef), the low VTEC carriage in pigs, the rarity of additional virulence factors (caeA) in VTEC isolated from cattle may explain the apparently low incidence of human diarrhoeal disease associated with VTEC in Hong Kong hitherto. However, the presence of non-O157 VTEC strains carrying the eacA virulence marker in cattle highlights the fact that sole reliance on sorbitol-MacConkey agar for screening human VTEC isolates may underestimate the human disease burden. The changing dietary habits of the population in Hong Kong reinforce the need for continued vigilance.

High-quality, cost-effective strategy for detection of autoantibodies to extractable nuclear antigens.

We evaluated methods for the detection of autoantibodies to extractable nuclear antigens (ENAs) to determine the strategy that yielded the most cost effective and clinically meaningful result. We prospectively compared counterimmunoelectrophoresis (CIEP) with and without serum prediffusion (SPD) and found that SPD significantly improved the quality of precipitation lines. This resulted in a decreased requirement for repeat testing and, consequently, was associated with a significant decrease in reagent costs and specimen turnaround time. We also retrospectively compared reactivity by CIEP, CIEP plus SPD, enzyme-linked immunosorbent assay (ELISA), and line immunoassay (LIA) of 52 serum samples that were previously determined to be positive for ENAs, and we correlated the results with clinical diagnoses. There was significant agreement among CIEP, CIEP plus SPD, ELISA, and LIA for the detection of anti-SS-A, anti-SS-B and anti-RNP. In general, CIEP, CIEP plus SPD, and LIA correlated better with the clinical diagnoses than ELISA, even though ELISA detected anti-ENAs more often than the other methods. CIEP plus SPD is therefore the most cost effective method for the identification of clinically meaningful ENAs. Based on our experience, we now screen for ENAs by CIEP, and positive samples are then typed by CIEP plus SPD. Samples that are difficult to interpret are then further assessed by an alternative method.

In vitro dissolution of cholesterol and brown pigmented gallstones: a comparison of MTBE, DMSO and BA-EDTA.

BACKGROUND: Gallstones are a common problem in Taiwan and surgical removal remains the essential treatment. Successful dissolution of the stones with chemical solutions and then removal by endoscopic or percutaneous methods have previously been reported. We designed this study to find the ideal agent for dissolving gallstones. METHODS: Twelve chemical solutions with dimethylsulfoxide (DMSO), methyl tert-butyl ether (MTBE) and ethylenediamine tetra-acetic acid (EDTA) in different mixtures were tested to investigate their ability to dissolve gallstones in vitro. The dissolution of stones was performed at 37 degrees C and each procedure was repeated five to seven times. RESULTS: The solvent containing DMSO/MTBE (1/1) had a higher dissolving capacity for cholesterol stones, with solubility reaching 96.8% after 6 hours. The solution containing DMSO/MTBE (7/3) had the maximal solubility for calcium bilirubinate stones, with solubility reaching 22.9% after 6 hours. Also, we found that the intact stones of calcium bilirubinate became fragmented after treatment with the DMSO/MTBE solution without stirring. CONCLUSIONS: The DMSO, MTBE and EDTA agents that we used effectively dissolved gallstones, especially cholesterol stones, in vitro. Further in vivo studies are necessary to confirm the efficacy and safety of these solvents before clinical application.

Pseudogastroparesis as a presentation of small-bowel malignancy.

Establishing the diagnosis of small-bowel malignancy is sometimes an extremely difficult challenge owing to its non-specific symptoms. The mainstay of treatment is early recognition, diagnosis and surgical resection. The prognosis depends primarily on the degree of spread and stage at presentation. We present two cases with initially obscure presentations of a small-bowel tumour. One was a jejunal adenocarcinoma, but an initial upper gastrointestinal and small-bowel series did not disclose the lesion; the other was a primary ileal lymphoma, first thought to be diabetes mellitus gastroparesis. Therefore, a negative small-bowel series or presentation of a systemic disease-associated intestinal pseudo-obstruction or gastroparesis does not exclude the possibility of a small-bowel malignancy, if the clinical symptoms are not alleviated after prokinetic medications. The clinicians should further pursue the possibility of an obstructing lesion.

The efficacy of the third pump inhibitor--pantoprazole--in the short-term treatment of Chinese patients with duodenal ulcer.

BACKGROUND/AIMS: To study the efficacy and tolerability of pantoprazole 40 mg once daily before breakfast compared with ranitidine 300 mg once daily at bedtime in Chinese patients with duodenal ulcer, and to evaluate the relationship between Helicobacter pylori (H. pylori) clearance and ulcer healing rate. METHODOLOGY: A total of 160 patients (80 in each group) with endoscopically diagnosed, active duodenal ulcers were studied in this randomized double-blind trial. Endoscopy was performed after 2 weeks of treatment. If unhealed, then the patients were re-endoscoped after an additional 2 weeks of similar treatment. RESULTS: The healing rates after 2 and 4 weeks were 61.3% and 97.3%, respectively in the pantoprazole group, and 50.7% and 76.9% in the ranitidine group. The difference between the two groups was significant at 4 weeks (p < 0.01, per protocol analysis). The rate of pain free ulcer was higher in the pantoprazole group than in the ranitidine group at 2 weeks (84.2% vs. 59.6%, p < 0.01). Higher clearance of H. pylori was also observed in the pantoprazole group compared with the ranitidine group at 4 weeks (20% vs. 0%, p = 0.05). The healing rate tended to be higher in patients who were H. pylori-cleared at 2 weeks (p = 0.07) in the pantoprazole group. Both medications were well tolerated without any serious adverse effects. CONCLUSIONS: Pantoprazole 40 mg daily is superior to ranitidine 300 mg daily in the short-term treatment of acute duodenal ulcer in Chinese patients, in terms of ulcer healing and pain relief, and appears to be well-tolerated.

Endothelin-1 is a candidate mediating intestinal dysmotility in patients with acute pancreatitis.

We studied whether gastrointestinal transit was disturbed during acute pancreatitis and attempted to identify which mechanisms might be involved in acute pancreatitis. Using a noninvasive hydrogen breath test to determine the orocecal transit time, 24 patients with the clinical diagnosis of acute pancreatitis were enrolled into the intestinal motility study. Orocecal transit time was measured twice in all patients: once at the acute stage and once at recovery. Blood was obtained to study amylase, lipase, C-reactive protein, erythrocyte sedimentation rate, and endothelin-1 and nitrate/nitrite levels. Orocecal transit times measured at the acute stage were significantly delayed compared with those at recovery (mean values +/- SEM, 130.0 +/- 9.0 vs 80.8 +/- 7.4 min, P < 0.001). Plasma endothelin-1 levels exhibited a positive correlation with orocecal transit times in the acute stage (r = 0.509, P = 0.011). The percentages of altered orocecal transit times also correlated with the percentages of altered plasma endothelin-1 levels (r = 0.751, P < 0.001). Plasma nitrate/nitrite levels significantly decreased at the acute stage compared with those at recovery (5.25 +/- 0.82 vs 10.20 +/- 1.24 microM, P < 0.05). We conclude that intestinal transit is delayed in patients with mild to moderate acute pancreatitis. Elevated plasma endothelin-1 levels in the acute stage may be one mechanism mediating intestinal dysmotility.

Hepatocellular carcinoma with mediastinal and pericardial invasion: report of two cases.

Mediastinal invasion with pericardial involvement in hepatocellular carcinoma (HCC) is rarely described. We report two patients with hepatitis-C-related HCC, who, after several courses of transcatheter arterial chemoembolization (TACE), developed mediastinal and pericardial neoplastic growth. Both patients presented with clinical manifestations of exertional dyspnea, chest pain and orthopnea. The diagnosis of HCC with pericardial involvement, through direct invasion of the anterior mediastinum, was established by computerized tomography and magnetic resonance imaging. These patients' symptoms were relieved after they received radiotherapy with a total dosage of 3,000 and 4,000 cGy over a three-week and four-week period, respectively. We suggest that direct mediastinal invasion with pericardial involvement should be considered when evaluating patients with advanced HCC who developed precordial distress following palliative TACE. Early recognition of this unusual complication is important in the management of HCC.

Magnesium citrate-bisacodyl regimen proves better than castor oil for colonoscopic preparation.

BACKGROUND: A clean colon preparation prior to endoscopy or X-ray examination is essential to obtain an accurate diagnosis. In order to determine which of two easily made preparations is better, this study compares colon cleansing efficacy, patient acceptance and side effects in patients given either a magnesium citrate-bisacodyl or a castor oil regimen prior to colonoscopy. METHODS: Seventy outpatients scheduled for colonoscopy were randomized to receive one of two bowel evacuation regimens on the day prior to the examination. Group 1 (n = 36) received a magnesium citrate solution (250 mL) and bisacodyl (10 mg, orally). Group 2 (n = 34) received castor oil (60 mL, orally). RESULTS: The cleansing effect of the magnesium citrate-bisacodyl regimen was significantly better than that of castor oil in the ascending colon and caecum (cleansing scores 5.2+/-1.2 vs 3.5+/-1.3, P< 0.0001), but similar to that of castor oil in the recto-sigmoid, descending and transverse colon. Abdominal pain (38 vs 11%, P< 0.01) and nausea (29 vs 8%, P<0.05) were significantly more common in patients receiving the castor oil preparation than in patients administered with the magnesium citrate-bisacodyl regimen. More patients complained of poor acceptance with the castor oil regimen than with the magnesium citrate-bisacodyl regimen (24 vs 8%, P=0.06). CONCLUSIONS: A combined oral magnesium citrate and bisacodyl regimen is effective and better than castor oil for colonoscopic preparation.

Characteristics of endoscopic retrograde cholangiopancreatogram in patients with primary biliary cirrhosis.

BACKGROUND: The findings of cholangiopancreatograms in patients with primary biliary cirrhosis vary markedly in literature. We tried to evaluate the changes of endoscopic retrograde cholangiopancreatograms in Chinese patients with primary biliary cirrhosis. METHODS: Twenty-nine patients with primary biliary cirrhosis underwent endoscopic retrograde cholangiopancreatography over the past 8 years. Three patients with a negative antimitochondrial antibody test were excluded. Well opacified cholangiograms and pancreatograms were obtained in 24 patients. Meanwhile, 16 subjects with normal cholangiopancreatogram served as controls. The characteristics and prevalence of abnormal cholangiopancreatograms in the patients and the correlation of radiography with clinical severity of the disease were evaluated. RESULTS: The maximum diameters of the common bile duct (9.7 +/- 4.0 vs. 7.6 +/- 0.9 mm, NS), right (5.0 +/- 1.6 vs. 4.4 +/- 1.2 mm, NS) and left (5.1 +/- 1.2 vs. 4.9 +/- 1.4 mm, NS) intrahepatic ducts did not show significant difference between the patients with primary biliary cirrhosis and the controls. Abnormal intrahepatic cholangiograms were obtained in 12 (50%) patients including eight with diminished arborization and focal stenosis, three with crowding and tortuous branches and one with focal stenosis alone. A hepatic hilum notch on the common hepatic duct was found in eight (33.3%) patients. The abnormalities of intrahepatic ducts did not correlate with age, sex, Pugh's scores, various liver function tests or histologically cirrhotic change. One (4.2%) patient had an abnormal pancreatogram. CONCLUSIONS: Abnormal intrahepatic cholangiograms are present in half of patients with primary biliary cirrhosis, but are not related to clinical severity.

Colonic mucosal changes in patients with liver cirrhosis.

BACKGROUND: Portal colopathy has been reported in patients with cirrhosis of the liver. The aim of this study is to evaluate colonic mucosal changes and their clinical significance. METHOD: Seventy-five cirrhotic patients with anemia and hemoccult-positive stool and 75 control subjects underwent endoscopic examinations of lower gastrointestinal tract. RESULT: Colonic ectasiae were found to be significantly more common in the 75 cirrhotic patients (80% with hepatitis B or C infection) than control subjects (84% vs 0, p < 0.0001). The lesions in 63 cirrhotic patients were found throughout the entire colon. They included colonic telangiectasiae or angiodysplastic-like lesions in 56 (89%) patients, red spots in 14 (22%), features suggesting mild chronic colitis in 8 (13%), and midrectal colorectal varices in 10 (16%). Pathologic findings in patients with telangiectasiae or angiodysplastic-like lesions showed dilation of vessels (7 of 9 patients) and edema of mucosa (6 of 9 patients). There was no correlation between the severity of cirrhosis, grade of esophageal varices, and the presence of colonic ectasiae. CONCLUSIONS: Our observations demonstrate that colonic mucosal changes commonly occur in cirrhotic patients with viral hepatitis. The risk of intermittent hemorrhage from colonic ectasiae should be considered in cirrhotic patients with anemia but without evidence of upper gastrointestinal bleeding. These characteristic lesions may represent a spectrum of portal in hypertensive intestinal vasculopathy.

Biliary motility following endoscopic sphincterotomy for recurrent common bile duct stones.

BACKGROUND: Recurrent common bile duct (CBD) stones after cholecystectomy are a common biliary tract disease. The role of biliary emptying in the formation of these stones is not yet well defined. METHODS: Cholescintigraphy was used to evaluate the biliary motility in 50 cholecystectomized patients with recurrent CBD stones after endoscopic sphincterotomy (EST) with stone extraction. Complete clearance of the CBD stones was confirmed in all patients by endoscopic retrograde cholangiopancreatography. Absence of sphincter of Oddi (SO) pressure after EST was determined by means of biliary manometry, and 99mTc-diisopropyl iminodiacetic acid (DISIDA) cholescintigraphy was performed four to six weeks after recovery from sphincterotomy. RESULTS: Complete clearance of the radioisotopes from the bile duct within 1, and more than 1 hour, was observed in 3 (6%) and 47 (94%) of the patients, respectively. When a cutoff value of 2 hours indicating abnormal biliary motility was employed, 31 out of the 50 patients (62%) had delayed biliary emptying. In comparing the clinical parameters between the two groups, patients with delayed biliary emptying time demonstrated an increase in CBD size greater than those of the normals (11.7 +/- 0.5 vs 9.2 +/- 0.4 mm, p < 0.05), while the presence of juxtapapillary diverticula and length of time for recurrence of CBD stones after cholecystectomy were not significant. Follow-up study showed that repeated recurrence rate of CBD stones appeared to be higher in the patients associated with delayed (12.9%) rather than normal (5.3%) biliary emptying. CONCLUSIONS: These results suggested that, in the absence of a functioning SO, abnormal biliary motility in cholecystectomized patients is one of the clinical factors involved in the pathogenesis of recurrent CBD stones.