Severe Gastrointestinal Bleed Caused by a Rectal Dieulafoy Lesion.

Dieulafoy lesions are vessels that erode the overlying epithelium without the presence of an ulcer. When these lesions bleed, they can frequently be self-limited, but bleeding can be recurrent and prolonged. Although most commonly found in the lesser curvature of the proximal stomach, there are reports of these lesions in other gastrointestinal tract regions. This case identifies a Dieulafoy lesion found in the rectum, which was the source of this patient's profuse rectal bleeding.

A colorimetric method for detection of K-ras codon 12 point mutations in DNA extracted from tissue and peripheral blood in pancreatic disorders.

Molecular-based methods to monitor point mutations require special and expensive equipment unavailable in most hospitals. Colorimetric-based analysis is an ideal platform for K-ras codon 12 gene point mutations because it uses commonly found hospital equipment. The colorimetric assay is sensitive and specific, detecting mutated DNA levels as low as 1% in a wild-type background. Paired genomic DNA extracts of fixed tissue and cellular fractions of peripheral blood are more sensitive and accurate than unpaired samplings. This approach has the potential to improve K-ras point mutation scans as well as to detect micrometastases in circulating tumor cells.

An Overview of the Evolution of Direct Cholangioscopy Techniques for Diagnosis and Therapy.

Direct examination of the biliary tree with endoscopes has been a challenge since endoscopists began performing endoscopic retrograde cholangiopancreatography (ERCP) in the late 1960s. Previously, surgeons had used rigid instruments intraoperatively, which made examination difficult. The first direct cholangioscopy performed by an endoscopist was likely unintentionally done in a patient with postsurgical anatomy. Indirect imaging, ERCP, and percutaneous transhepatic cholangiography are helpful modalities for examining the biliary tree, but they are limited procedures, particularly with regard to the evaluation and treatment of strictures and bile duct stones. This article reviews the history and evolution of direct cholangioscopy since the advent of flexible endoscopes. Additionally, the article describes a new single-operator cholan-gioscopy technique for direct visualization of the biliary tree for diagnosis and intervention. There remains opportunity for innovation as endoscopists strive for safe and less-invasive methods for the identification and treatment of biliary pathology.

Autoimmune Pancreatitis: A Multiorgan Disease Presenting a Conundrum for Clinicians in the West.

Autoimmune pancreatitis (AIP), a clinical entity originally described in East Asia and more recently recognized in the United States and Europe, poses a diagnostic conundrum for clinicians in the West due to immunoglobulin G4 seronegativity. Although expert panels classify this disease into 2 types, it remains difficult to stratify the disease given that both types share most clinical, biochemical, and imaging characteristics. The classic presentation of AIP can mimic that of pancreatic carcinoma, which increases the urgency of evaluation, diagnosis, and treatment. In this article, we elucidate the differences between the 2 types of AIP, highlight the shortcomings of the current classification system, and propose a more inclusive view of the disorder.

Treatment of pancreatic strictures.

The diagnosis and treatment of patients with pancreatic strictures presents a multitude of clinical challenges. The etiology of pancreatic strictures is varied, including benign strictures subsequent to acute pancreatitis, trauma, postsurgical, post-endoscopic retrograde cholangiopancreatography (ERCP), and malignancy. Patients with strictures usually present with symptoms of recurrent pancreatitis, abdominal pain, weight loss, and/or steatorrhea. The absence of a prior history of pancreatitis or surgery increases the likelihood of malignancy. High-quality imaging studies of the pancreas, CT, MRI/magnetic resonance cholangiopancreatography, or endoscopic ultrasound (EUS) scanning are utilized for better definition. Imaging detects an associated mass and/or demonstrates the ductal anatomy. Invasive procedures such as ERCP are performed to better define the causal relationships of the patient's symptoms or to obtain tissue diagnosis. Treatment goals include ameliorating symptoms, dilating the stricture, and ruling out cancer. The risk of malignancy underlies much of the intervention, which includes serology, cytologic analysis, and serial imaging. EUS has become the procedure of choice to rule out a mass, to evaluate the parenchyma for evidence of chronic pancreatitis, and to obtain fine-needle biopsies for tissue confirmation. In symptomatic patients or patients with indeterminate strictures, ERCP is used for direct pancreatography, tissue acquisition, and endoscopic treatment. Endotherapy includes sphincterotomy, dilation, and stenting to provide drainage. We view ERCP as the optimal first-line treatment modality. ERCP offers the potential of curative treatment and is less invasive than surgery, especially as some patients' symptoms are not severe enough to justify surgery. If patients do not experience relief of symptoms after several sessions of endoscopic therapy, surgery is the logical next step for definitive, long-term treatment.

Sphincter of Oddi manometry does not predispose to post-ERCP acute pancreatitis.

BACKGROUND: Sphincter of Oddi manometry is helpful in selecting patients with sphincter of Oddi dysfunction who will respond to sphincterotomy. However, studies have shown that sphincter of Oddi manometry is associated with a high risk of post-procedure pancreatitis. The primary objective of this study was to evaluate the safety of sphincter of Oddi manometry in patients with sphincter of 2Oddi dysfunction. The secondary objective was to determine the risk factors for post-ERCP pancreatitis in patients with sphincter of Oddi dysfunction. METHODS: Data were collected retrospectively for 268 patients who had elective ERCP performed at 3 tertiary care medical centers between 1996 and 2000. Consecutive patients with suspected sphincter of Oddi dysfunction formed the case group; the control group consisted of patients with bile duct stone. The case group was further subclassified into group A, patients who underwent sphincter of Oddi manometry followed by immediate ERCP, and group B, patients who had ERCP without manometry. The rate of post-ERCP acute pancreatitis was compared between case and control groups. RESULTS: Twenty-seven percent of patients in the case group with suspected sphincter of Oddi dysfunction developed acute pancreatitis compared with 3.2% of patients in the control group with bile duct stone (p<0.001). There was no significant difference in the rate of acute pancreatitis in patients with sphincter of Oddi dysfunction who underwent sphincter of Oddi manometry and ERCP compared with patients with sphincter of Oddi dysfunction who had ERCP without sphincter of Oddi manometry (odds ratio 0.72: 95% CI[0.08, 9.2]). Multivariable logistic regression analysis showed that biliary sphincterotomy (p=0.006) and pancreatography (p=0.03) were independent predictors of acute pancreatitis. CONCLUSIONS: Patients with suspected sphincter of Oddi dysfunction are at higher risk of post-ERCP acute pancreatitis. Sphincter of Oddi manometry by itself does not appear to predispose to this complication.