Assessment of Mucosal Inflammation and Circulation in Response to Probiotics in Patients Operated with Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

BACKGROUND: Pouchitis is a common and troublesome condition, and a disturbed microbiological flora and mucosal blood flow in the pouch have been suggested as possible causes. Laser Doppler flowmetry (LDF) has been used successfully to measure gastric and colonic mucosal perfusion in humans. The aim of this study was to evaluate the effect of intervention with probiotics on ileal pouch inflammation and perfusion in the pouch, assessed by endoscopy, histology, fecal calprotectin and LDF. METHODS: A fermented milk product (Cultura; 500 ml) containing live lactobacilli (La-5) and bifidobacteria (Bb-12) was given daily for 4 weeks to 10 patients operated with ileal-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Mucosal perfusion was measured with LDF and the degree of inflammation was examined at predefined levels of the distal bowel by endoscopy and histology. Stool samples were cultured for lactobacilli and bifidobacteria and calprotectin were measured before and after intervention. RESULTS: The LDF measurements were reproducible in the pelvic pouch at each of the predefined levels, but did not change after intervention. The mucosal perfusion was reduced in the distal compared to the proximal part of the pouch. Calprotectin levels did not change significantly after intervention. The median endoscopic score for inflammation was significantly reduced by 50% after intervention, whereas the histological score did not change significantly. CONCLUSION: The results suggest that probiotics primarily act superficially, with change of gross appearance of the mucosa at endoscopy, but without significant effect on histological picture, mucosal perfusion or faecal calprotectin, during a relatively short period of 4 weeks.

Two simultaneously occurring hypopharyngo-oesophageal diverticula.

We report a case of two simultaneously occurring hypopharyngeal-oesophageal diverticula, one apparently originating above, the other below the cricopharyngeal muscle. The radiological and clinical findings of this rare condition are presented.

Acute appendicitis in patients with Gilbert's syndrome.

Gilbert's syndrome is a benign disorder characterized by intermittent hyperbilirubinemia. Jaundice is provoked by anorexia and fever, conditions associated with acute abdominal illnesses. Three cases of Gilbert's syndrome and acute appendicitis are presented. The presence of jaundice resulted in errors of diagnosis with serious complications.

The composition of biliary calculi in patients with juxtapapillary duodenal diverticula.

Biliar calculi from 32 patients with juxtapapillary duodenal diverticula were analyzed by quantitative infrared spectroscopy. In 22 of the patients the calculi were classified as pigment stones and in 10 as cholesterol stones. Calcium bilirubinate was the main component in the pigment stones, with a median value of 45%; the median cholesterol content was 7.5%. In the cholesterol stones median calcium bilirubinate content was 1% and median cholesterol content 95.5%. Calcium carbonate was found in small amounts in only nine of the calculi. The findings support our theory that the pigment calculi in patients with juxtapapillary diverticula are caused by ascending infections to the bile ducts with intestinal beta-glucuronidase-producing bacteria. Beta-glucuronidase will split the conjugated bilirubin in bile into glucuronic acid and unconjugated bilirubin, which in turn combine with calcium to form insoluble calcium bilirubinate.

[Results after emergency surgery and ileoanal anastomosis in ulcerative colitis]. / Resultater etter akutt kirurgi og ileoanal anastomose ved ulcerøs kolitt.

BACKGROUND: Patients suffering from severe ulcerative colitis often receive emergency colectomy at vital indication. Some of them are offered an ileal pouch-anal anastomosis a few months later. MATERIAL AND METHODS: All patients (n = 80) from May 1985 to August 1998 who were subjected to emergency colectomy at the National Hospital of Norway because of severe ulcerative colitis were studied prospectively. 40 patients later underwent a successful ileal pouch-anal anastomosis operation; 36 of them were sent a questionnaire assessing anal function. RESULTS: No patients died during admission or within 30 days of emergency colectomy. Five patients (6%) developed postoperative complications requiring reoperation. 31 patients returned the questionnaire. All reported full bowel control, although two used pads during night. Mean number of evacuations per 24 hours was six. 14 patients (45%) usually had evacuations during night. All patients would prefer ileal pouch-anal anastomosis if they were given the choice between this and permanent ileostomy again. 87% were satisfied with the operation result, 10% were moderately satisfied, 3% were not satisfied. INTERPRETATION: The results of urgent colectomy are good, and patients aged < 50 may expect good anal function after receiving ileal pouch-anal anastomosis.

Juxtaminorpapillary diverticulum associated with chronic pancreatitis.

A 69-years-old male with a juxtaminorpapillary diverticulum of Santorini in the duodenum and chronic pancreatitis is described. The patient had suffered from attacks of epigastric pain during the last 35 years. At recent admission to hospital he had also an elevated urinary amylase activity and a juxtaminorpapillary diverticulum, demonstrated by duodenoscopy and X-ray examination after administration of a contrast medium. Endoscopic retrograde cholangio-pancreatography (ERCP) showed changes of the pancreatic duct system compatible with chronic pancreatitis, a diagnosis which was confirmed by explorative laparotomy.

Multiple mesenteric cysts diagnosed by ultrasound. A case report.

The diagnostic value of ultrasound in mesenteric cysts in infancy and childhood is demonstrated by a case report of a 4 year old girl with multiple cysts in the transverse mesocolon and with no other symptoms or signs than an enlargement of the abdomen. Neither clinical nor radiological examination could give the diagnosis, whereas ultrasound examination promptly revealed large, thin-walled, partly locular, cystic masses.

[Surgical treatment of esophageal cancer]. / Kirurgisk behandling av kreft i spiserøret.

BACKGROUND: Oesophageal cancer is a serious condition with low long-term survival. The objective of this study was to define procedural safety and survival following tumour resection. MATERIAL AND METHODS: All 46 patients (41 men) operated for oesophageal cancer at the National Hospital, Oslo, Norway between 1987 and 1994 were reviewed. Median age was 61 years. 23 patients had squamous epithelial carcinoma and 20 had adenocarcinoma. Right-sided thoracotomy combined with laparotomy was performed in 38 patients (83%). RESULTS: Serious complications occurred in 17 patients (37%). Seven patients developed postoperative anastomotic leakage. Eight patients were reoperated due to complications. Perioperative mortality was 13%. Surveillance time at the intensive care unit was median eight days; nine patients stayed at the intensive care unit for more than 20 days. Three and five year survival for patients with adenocarcinoma were 30% and 20% respectively, and for patients with squamous cell carcinoma 18% and 14%. INTERPRETATION: Surgical treatment of oesophageal cancer has high morbidity and mortality. Long-term survival is achieved in only few patients.

Perforated appendicitis--lavage or drainage?

A comparison was made regarding the observed frequency of intraperitoneal complications between two groups of patients operated upon for perforated appendicitis during a 5-year period (1968-73). The two groups, corresponding to two different general surgical departments at the same hospital, were given different forms of adjuvant treatment. The first group (78 patients) received postoperative intraperitoneal lavage, with antibiotics added to the lavage solution. In the other department (77 patients), the peritoneal cavity was drained postoperatively. No lavage was performed in this group, but antibiotics were given systemically. Sixteen patients in the drainage group developed intraperitoneal complications, as compared with 5 in the lavage group.

Bacteriological studies of common duct bile in patients with gallstone disease and juxta-papillary duodenal diverticula.

Bile samples from the common duct were collected at cholecystectomy and cultivated aerobically and anaerobically. Two groups of patients were studied, patients with juxta-papillary duodenal diverticula and patients without diverticula. All patients had chronic cholecystitis and concrements in the gallbladder, but no biliary obstruction. A significantly higher incidence of positive cultures was found in patients with diverticula than in the control group. The positive samples contained bacterial species belonging to the intestinal flora. We propose an ascending route of infection and assume that bacteria may play a role in the formation of gallstones so often seen in patients with juxta-papillary duodenal diverticula.

Recurrent biliary calculi: duodenal diverticula as a predisposing factor.

Several studies indicate a causal relationship between duodenal diverticula and gallstone disease. The diverticula persist after biliary tract surgery, and it is therefore presumed that patients with diverticula have an increased disposition to develop new calculi in the bile ducts after cholecystectomy. To test this hypothesis, the occurrence of recurrent biliary calculi was studied in 101 patients who had cholecystectomy, all with an asymptomatic period of two years or more following the primary biliary surgery. All patients had symptoms, that indicated biliary tract or pancreatic diseases. The incidence of recurrent calculi in patients with diverticula was 87.5% (95% confidence interval, 66.9-95.8). In patients without diverticula, the incidence was 31.9% (95% confidence interval, 21.5-44.3). The difference is highly significant, and the results support the assumption tht diverticula in the area of the papilla of Vater dispose to gallstone disease.

Juxtapapillary duodenal diverticula.

This paper presents a review of the clinical significance of juxtapapillary duodenal diverticula in man. The incidence of such diverticula varies considerably in the literature, and possibly depends on the methods of investigation used. Studies show that the incidence of biliary calculi is significantly higher in patients with juxtapapillary diverticula as compared with patients without such diverticula. The assumed higher rate of diverticula in patients with pancreatitis is probably due to the presence of biliary calculi in these patients. Studies have shown that there is an insufficient choledochoduodenal sphincter in patients with diverticula, and also a higher rate of bacterial contamination of the duodenum and bile ducts in these patients. Fecal type flora has been found in most patients with juxtapapillary duodenal diverticula. Further, pigment gallstones have been found in most patients with diverticula, and analyses of these calculi showed that calcium bilirubinate was the main component. Further studies in our laboratory have shown that bacterial cultures produced beta-glucuronidase, a fact which may be connected with the increased frequency of pigment gallstones. Other studies have shown that there is a higher rate of diverticula in patients with recurrent biliary calculi who had undergone cholecystectomy. Recent data have also shown that there is a higher rate of common bile duct calculi in patients with diverticula, than in those without diverticula and without prior cholecystectomy--a fact supporting the theory on the pathogenesis of biliary calculi in patients with juxtapapillary diverticula. Other, and rare complications due to such diverticula are also mentioned.

Juxtapapillary duodenal diverticula predispose to common bile duct stones.

In an endoscopic study of 107 patients with suspected common bile duct calculi, 26 were found at retrograde cholangiography to have juxtapapillary diverticula (JPD). Over 80% of these patients had common bile duct calculi, compared with only 52% among those without any JPD (p less than 0.01).

Biliary pigment and cholesterol calculi in patients with and without juxtapapillary duodenal diverticula.

The occurrence of pigment and cholesterol calculi was studied in 45 patients with concrements in the gallbladder but no calculi in the common or intrahepatic bile ducts. Twenty-one of the patients had juxtapapillary duodenal diverticula diagnosed by duodenoscopy. Twenty-four patients had no diverticula. The classification of the calculi as pigment stones or cholesterol stones was based on quantitative determination of the cholesterol contents. Calculi with a cholesterol content of less than 25% were classified as pigment stones; calculi with a cholesterol content of more than 25% were classified as cholesterol stones. All pigment stones had a cholesterol content of less than 20%. With the exception of four patients the cholesterol content was over 70% in all cholesterol stones. Twelve of the 21 patients with were classified as pigment stones; calculi with a cholesterol content of more than 25% were classified as cholesterol stones. All pigment stones had a cholesterol content of less than 20%. With the exception of four patients the cholesterol content was over 70% in all cholesterol stones. Twelve of the 21 patients with were classified as pigment stones; calculi with a cholesterol content of more than 25% were classified as cholesterol stones. All pigment stones had a cholesterol content of less than 20%. With the exception of four patients the cholesterol content was over 70% in all cholesterol stones. Twelve of the 21 patients with diverticula had pigment stones, whereas only 1 of the 24 patients without diverticula had pigment calculi, a difference that was statistically significant (p less than 0.01).

Studies of the choledocho-duodenal sphincter in patients with and without juxta-papillary duodenal diverticula.

The function of the choledocho-duodenal sphincter was studied in 16 patients, 8 with juxta-papillary duodenal diverticula. All patients had calculi in the gallbladder. The common bile duct was normal. At cholecystectomy two catheters were introduced into the common bile duct through the stump of the cystic duct and fixed in place. The examinations were performed when the patients had recovered from the operation. One catheter was connected to a pressure transducer, the other was used for saline infusions. Pressure in the common duct was recorded before infusion and at constant infusion rates of 3,6, and 12 ml/min. The muscular tone, the contractile activity, and the total rhythmic variations of the sphincter during infusions were all significantly less in patients with diverticula than in the controls without diverticula. The findings indicate that there is a dysfunction of the choledochoduodenal sphincter in patients with juxta-papillary duodenal diverticula. This may in part be responsible for the high incidence of biliary calculi in patients with duodenal diverticula.

Juxtapapillary duodenal diverticula and abnormalities by endoscopic retrograde cholangio-pancreatography (ERCP).

In a consecutive series of 174 patients the biliary and pancreatic ducts were demonstrated by endoscopic retrograde cholangio-pancreatography (ERCP). In 84 patients with normal duct systems, juxtapapillary diverticula were found in 5 patients (6%). In 90 cases with ductal abnormalities due to biliary concrements, dilated common bile duct and pancreatitis, diverticula were found in 35 patients (39%). In patients with abnormalities in both duct systems, diverticula were found in 52%, and in patients with changes in one duct system diverticula were found in 33%. The difference in occurrence of diverticula in patients with normal duct systems and pathological duct systems was statistically significant (p less than 0.02). The findings indicate a correlation between juxtapapillary diverticula and pathological changes due to biliary concrements, dilated common bile duct without concrements and pancreatitis.

Early gastric carcinoma in patients with a Billroth II partial gastrectomy.

In a consecutive series of 830 routine gastroscopies a total of 43 patients was found with gastric carcinomas, Thirteen of these were patients with a previous Billroth-II operation for ulcer disease. Early cancers were found in ten patients (23%), and four of these ten (3 men, 1 woman, aged 49 to 76 years), had been operated on 20-33 years previosuly with a Billroth II partial gastrectomy. All patients had symptoms indicating gastro-intestinal disease. We conclude that a high number of gastric stump carcinomas may be detected at an early stage, and that endoscopy of the whole gastric stump, with multiple biopsies and brush cytology from the entire gastro-jejunal anastomosis, is of crucial importance in detecting such carcinomas.

The probability of pancreatitis after pancreatic parenchymatography with a non-ionic contrast medium. A sequentially designed clinical trial.

Endoscopic retrograde pancreatography (ERP) with parenchymatous contrast filling may result in clinical pancreatitis. The aim of the present prospective trial was to assess the frequency of acute pancreatitis after pancreatic parenchymatography with a non-ionic contrast medium, metrizamide. For ethical reasons the examination was designed as a sequential study with clearly defined stopping rules. None of the 48 patients studied developed clinical pancreatitis. This indicates that the probability of pancreatitis after parenchymatography is less than 5%. A high degree of contrast filling was obtained both in patients with normal and in those with pathologic pancreatic ducts. The contrast filling of the ducts was associated with not more than a slight pain. The rise in serum amylase was considerable but was not associated with clinical pancreatitis and returned to preexamination levels within 48 h. The examination shows that the non-ionic contrast medium used is well tolerated in ERP.

Peritoneal lavage with doxycycline in acute diffuse peritonitis.

Peritoneal lavage with ten hourly repeated instillation-drainages of one litre lavage fluid containing 50 mg doxycycline (Vibramycin Pfizer) was carried out on six patients suffering from diffuse peritonitis due to perforated appendicitis. Bacteriological specimens were obtained both from the perforation in the appendix and the peritoneal fluid at operation and the doxycycline concentrations in blood and lavage fluid were determined at intervals up to 72 hours postoperatively. All the patients recovered, but the lavage was considered a failure in one case as a small abscess and multiple adhesions were found at reoperation 1 1/2 months later. Bacteriological swabs from the perforated appendix and the peritoneal fluid usually contained the same bacteriological species, and as a rule several species were isolated. Doxycycline compared favourably with ampicillin as regards bacterial sensitivity, but the difference was too slight to be of practical importance. Doxycycline was absorbed very rapidly from the peritoneal cavitiy, and due to its slow excretion a cumulation occurred. In this small series doxycycline did not appear to give any real advantage over ampicillin, but it may be considered the drug of choice in patients with penicillin allergy, and in those who fail to respond to ampicillin.