Endoscopic retrograde cholangiopancreatography.

The ERCP report in the patient's chart was compared with findings on common duct exploration or cystic duct cholangiography in 72 patients and found to have a sensitivity of 90.4 percent, a specificity of 98 percent, and an accuracy of 95.8 percent. Factors having the potential to influence the accuracy of ERCP were errors in interpretation by the surgeon and the radiologist and the operative technique of cholecystectomy. Also, the interval between the performance of the procedure and operation was particularly important in the patient with multiple small gallstones or small common duct stones. Small gallstones may spontaneously pass from the gallbladder to the common duct, or small common duct stones may spontaneously pass into the duodenum; therefore, the longer the interval between ERCP and operation, the greater the likelihood of a discrepancy. At operation, gallstones may be squeezed into the common duct during manipulation of the gallbladder unless the cystic duct is obstructed before manipulation of the gallbladder. We found ERCP sufficiently accurate to make cystic duct cholangiography unnecessary in most patients with cholelithiasis having a preoperative ERCP examination.

Diagnosis of gangrene and perforation of the gallbladder by endoscopic retrograde cholangiography.

Conventional radiographic procedures are not helpful in the preoperative documentation of gangrenous cholecystitis or gallbladder perforation. Three cases in which preoperative diagnosis was accomplished by endoscopic retrograde cholangiography are described. Gangrene was identified in all three by a shaggy outline of the gallbladder wall with amorphous debris and stones in the lumen. Perforation was identified in two of the cases by extravasation of contrast material into a pericholecystic abscess. This information, as well as the status of the common duct, was important to the surgeon.

Fusion anomalies of the pancreatic ductal system differentiation from pathologic states.

If fusion of the ventral and dorsal pancreatic ducts does not occur during fetal life, endoscopic retrograde cannulation of the papilla of Vater will visualize a small complete ductal system which is confined to the head of the pancreas. This system is characterized by normal arborizations throughout, relatively small duct diameters and the absence of a communication with the minor papilla. In contrast, if fusion has taken place and the ductal system is shortened by disease, pancreatography will demonstrate abrupt proximal termination or proximal tapering without side branches, and may show a significant duct of Santorini. If the ducts have fused, an area of narrowing approximately 3-20 mm in length commonly occurs at the level of fusion. This should not be confused with pathologic ductal stenosis.

Influence of age on the clinical presentation of acute biliary tract disease.

The influence of age on the presenting manifestation of acute biliary tract disease was evaluated by retrospective review of all cases in which this diagnosis was confirmed at operation over a 30-month period. Results indicated that acute biliary tract diseases in elderly patients presents in a manner not statistically significantly different from younger patients (p greater than 0.05 for all parameters studied). Although such disorders in the elderly occasionally present in an unusual fashion, the majority of older patients present with abnormalities such as pain, jaundice, fever, and leukocytosis as commonly or even more frequently than younger patients.

Metastatic lung carcinoma involving the gastrointestinal tract.

A review of 147 autopsies performed over a 4.5-year period on patients with a diagnosis of primary carcinoma of the lung revealed that 18 (12%) had metastatic lesions in the gastrointestinal tract. Fourteen had a single focus of gastrointestinal involvement, while four had multiple lesions in the gastrointestinal tract. Large cell carcinoma accounted for a large percentage (33%), out of proportion to the general occurrence of this cell type (12%). Twelve of the 18 patients had signs or symptoms suggesting gastrointestinal involvement but only four were diagnosed premortem. Gastrointestinal involvement in metastatic carcinoma of the lung occurs more frequently than realized and is often overlooked.

Malabsorption following radiation therapy.

Gastrointestinal injury is known to occur following radiation therapy of tumors in the abdominopelvic compartment. Chronic radiation changes may be associated with diarrhea and malabsorption. A patient with transitional cell carcinoma of the bladder developed diarrhea following radiotherapy and was treated symptomatically for nine years with the assumption that the diarrhea was secondary to radiation enteritis. Further evaluation including endoscopic cholangiopancreatography, revealed pancreatic insufficiency with steatorrhea as the probable cause of the patient's diarrhea. Although temporally related to radiation therapy, the etiology of his pancreatic insufficiency remains speculative. All patients developing diarrhea and/or malabsorption following radiotherapy should be evaluated thoroughly for treatable causes.

Watery diarrhea syndrome with elevated levels of vasoactive intestinal polypeptide associated with pancreatitis and pancreatic pseudocyst.

A 32-year old patient presented with recurrent pancreatitis, severe watery diarrhea and elevated serum levels of vasoactive intestinal polypeptide. His diarrhea appeared to respond to intramuscular propantheline. Initially he improved but had another attack of pancreatitis while hospitalized. Evaluation by ultrasound revealed the presence of a pseudocyst and endoscopic retrograde pancreatography demonstrated complete occlusion of the main pancreatic duct. Exploratory laparotomy was performed with drainage of a pseudocyst. Analysis of the pseudocyst fluid revealed an elevated amylase, lipase and vasoactive intestinal polypeptide level. It is believed that this patient's severe diarrhea was related to his pancreatitis and pancreatic pseudocyst with elevated levels of vasoactive intestinal polypeptide.