Hemobilia after liver biopsy. Early detection in a patient with mild hemophilia A.

Hemobilia occurred following liver biopsy in a patient with mild hemophilia A, despite adequate factor VIII transfusion. Before major hemorrhage occurred, the diagnosis of hemobilia was confirmed by endoscopy and retrograde cholangiography. Two aneurysms of the hepatic artery were found in the corresponding area of puncture injury. Surgical intervention was necessary for hydrops of the gallbladder with cholecystitis caused by blood clots occluding the cystic duct. The bleeding stopped spontaneously. Early endoscopy and retrograde cholangiography are beneficial in elucidating the exact cause and relationship of clinical signs and symptoms.

Omeprazole (20 mg o.m.) versus ranitidine (150 mg b.d.) in duodenal ulcer healing and pain relief.

The object of this double-blind, multicentre study was to compare duodenal ulcer healing rates after 2 to 4 weeks of treatment with either 20 mg omeprazole o.m. or 150 mg ranitidine b.d. One hundred and eighty-one patients were randomized: 91 received omeprazole and 90 received ranitidine. In a per protocol analysis at 2 weeks, 63% of the patients were healed on omeprazole and 65% of the patients were healed on ranitidine (N.S.); at 4 weeks 91% were healed in the omeprazole group and 96% were healed in the ranitidine group. There were no differences in ulcer symptom relief between the two groups. There were no significant changes in laboratory values in either of the groups. Adverse events were few and mainly mild and transient. We conclude that both omeprazole (20 mg o.m.) and ranitidine (150 mg b.d.) result in rapid, ulcer healing rates.

Vascular ectasias (angiodysplasias) of the cecum and the ascending colon.

Over a period of two years (1977-1979) the diagnosis symptomatic vascular ectasias of the colon was made in 7 patients. The authors describe 3 cases with corresponding illustrations. The diagnostic value of selective mesenteric artery angiography and fiber endoscopy for the diagnosis and treatment is stressed. The possible pathogenesis of the vascular abnormality is discussed with reference to the histology and the literature.

Endoscopic retrograde cholangiopancreaticographic aspects of choledocholithiasis and its sequelae.

100 patients with a known history of choledocholithiasis were selected. The main reasons for performing ERCP were the presence of severe jaundice or insufficient information obtained with intravenous cholangiography. Analysis is made of the various complications due to the presence of common bile duct stones. A surprisingly high incidence of choledochoduodenal fistulas was seen; two types of such fistulas can be recognized. A brief discussion is given of etiological factors involved. ERCP is also very useful in the evaluation of surgical anastomosis and complications due to surgery such as narrowing or complete ligation of the common bile duct. Finally, pancreatitis, another complication of choledocholithiasis, is evaluated with ERCP, showing the importance of reflux from the common bile duct into the pancreatic ducts in the etiology of this condition.

Loperamide in the symptomatic control of chronic diarrhoea. Double-blind placebo-controlled study.

Fifteen patients (20-66 years) with persistent diarrhoea of varying aetiology were selected for an open trial of loperamide 2 mg capsules. The optimal daily dose for substantial reduction of the diarrhoea ranged from two to seven capsules. Eleven patients showed a significant improvement in stool consistency, a highly significant decrease in stool frequency and a decrease of abdominal cramps. One ileostomy patient with abundant ileostomy output and intermittent leaking of the ileosotmy appliance at night experienced a substantial reduction of the stoma output with virtual disappearance of soiling accidents as night. Loperamide appeared to be ineffective in two patients with cholerrhoeic diarrhoea; in one patient with laxative-induced diarrhoea and in one patient with probable nervous diarrhoea. The eleven successfully treated patients then entered a doubleblind placebo-controlled trial for ten days or util relaps, the daily dose being indentical to the optimal one previously determined in the open phase of the study. The investigator was able to guess the code correctly in ten out of eleven cases. The drug was well tolerated. Because of its considerable efficacy and low side-effect liability, loperamide has to be considered a promising drug in the treatment of chronic diarrhoea.

In vitro and in vivo analysis of the PABA test compared with the Lundh test--influence of intraluminal pH.

Lundh test and PABA test results were compared in 50 patients. In the resulting correlation curve three areas of interest were differentiated: (1) an area with mean tryptic activity, found in the Lundh test, below 4 U/ml, where an abnormal PABA test result was also seen; (2) an intermediate area from 4 to 9 U/ml, where PABA test results may be found in discordance with the Lundh test; (3) the normal level, where PABA excretion was shown to be independent of intestinal chymotrypsin activity. In experiments in vitro on the kinetics of the hydrolysis of BTPABA by chymotrypsin the profound influence of the pH on Km and Vmax was shown. This influence of the pH explains why in the intermediate area of pancreatic dysfunction normal PABA test results were found in a number of cases. A higher mean pH level of the Lundh test aspirates was found for patients with a normal PABA test result than for patients with an abnormal PABA test.

Endoscopic ultrasonography of non-Hodgkin lymphoma of the stomach.

Endoscopic ultrasonography was performed in 8 patients with non-Hodgkin lymphoma of the stomach. Findings consisted of intramural infiltration or mucosal alteration together with perigastric lymph nodes, or both. Lymph node involvement was suggested by the presence of inhomogeneous hypoechoic echopatterns with clearly demarcated borders. Endoscopic ultrasonography was more accurate than computed tomography scan in the detection of transmural extent of malignancy and adjacent lymph node involvement. Because of the limited penetration depth of endoscopic ultrasonography, approximately 10 cm, more distant lymph nodes might be more clearly detected with computed tomography scan. Endoscopic ultrasonography was also more accurate than endoscopy and barium meal in the assessment of gastric wall infiltration. The resectability of gastric non-Hodgkin lymphoma was reliably detected by endoscopic ultrasonography before surgery. Endoscopic ultrasonography appears to be a sensitive diagnostic modality for detection, staging, and follow-up in gastric non-Hodgkin lymphoma. Technical improvements may further enhance the diagnostic value of this new procedure.

Modulation of gastrin release by acute changes in plasma calcium.

Gastrin release was studied in 5 hypergastrinemic patients, both during calcium infusion and EDTA infusion. In each patient, gastrin decreased in conjunction with the fall in plasma calcium, and increased during calcium infusion. Plasma gastrin and calcium levels were strongly correlated.

A new surgical approach for the management of carcinoma of the junction of the main hepatic ducts.

In the present study we discuss our early results and some technical aspects of a new surgical approach in dealing with high-lying malignant biliary obstruction. After transection of the common bile duct we proceed through a cephalad reflection of its proximal end in a meticulous dissection of the intrahepatic biliary tree. During dissection we follow the intrahepatic course of the right and left portal vein, which leads us to follow the respective course of the main right and left hepatic ducts and to reach the levels of their subsequent consecutive segmental bifurcations. By transecting at high levels, we excise completely or partially the tumor with the confluence of common hepatic duct. We reconstruct the biliary tree by multiple intrahepatic cholangiojejunostomies by use of a Roux-Y jejunal loop and a varied number of segmental hepatic ducts. Transanastomotic tubes were used only temporarily. Fifteen patients underwent operations by the described surgical approach without mortality. All were relieved of their jaundice completely and in all the tumor was either completely (5) or partially (10) removed. All patients had a good quality of postoperative life without being obliged to carry transanastomotic tubes and the complications and problems associated with them.