Biliary ascariasis--a worm in the duct.

OBJECTIVE: Migration of Ascaris lumbricoides into the biliary tree may cause biliary obstruction, cholangitis or pancreatitis. Although common in endemic areas, none of these complications have previously been reported in Australia. We report here a case of obstruction of the common bile duct by an ascarid. CLINICAL FEATURES: A 62-year-old female Vietnamese migrant presented with cholangitis and underwent a cholecystectomy. Subsequently, ultrasound and cholangiography revealed an ascarid in the common bile duct. INTERVENTION AND OUTCOME: This worm was endoscopically removed and the patient's symptoms rapidly resolved. CONCLUSION: As a result of increased migration to Australia, such cases will be recognised more frequently in the future. Patients at risk should be carefully imaged prior to definitive therapy.

Endoscopic management of malignant biliary obstruction: stents of 10 French gauge are preferable to stents of 8 French gauge.

To assess whether the use of large stents is justified, we have retrospectively reviewed the results of 8 French gauge (FG) stents with pigtails and 10 FG straight stents in the palliation of biliary obstruction due to malignancy. The incidence of cholangitis following stent insertion was significantly lower with 10 FG stents, 3 (5%), compared with 8 FG stents, 13 (34%), p less than 0.001, chi 2. Stent survival until blockage was significantly longer for 10 FG (median 32 weeks) compared with 8 FG (median 12 weeks), p less than 0.001, log-rank. The superior performance of the 10 FG stents was due to their larger diameter which gives them a flow capacity much greater than the physiological bile flow. We recommend that stents of at least 10 FG diameter are used for the endoscopic palliation of biliary obstruction due to malignancy.

Rhinocerebral mucormycosis.

Two cases of rhinocerebral mucormycosis are reported to draw attention to this fulminating fungal disease. Both patients had diabetes, and presented with a rapidly progressive orbital apex syndrome.

Training in sigmoidoscopy. An assessment in three teaching hospitals.

To assess the standard of training in postgraduate sigmoidoscopy in Melbourne, a questionnaire was prepared and distributed to resident medical officers (RMOs) in three teaching hospitals. The survey showed that practical instruction in technique is inadequate, and that most individuals perform too few sigmoidoscopies to become competent at either examining or recognizing lesions. A substantial number of RMOs had never seen common and important lesions such as polyps or colorectal cancer. Most RMOs considered their training to be poor and stated that they lacked confidence in their ability to perform sigmoidoscopy. The current training programme needs detailed reassessment and improvement.

Extracorporeal shock-wave lithotripsy and the management of common bile-duct calculi.

Endoscopic sphincterotomy is the treatment of first choice for stones that remain in the bile duct after cholecystectomy. There is a small group of patients in whom this technique is not successful; many of these patients carry a high risk for surgery because of their age or associated medical conditions. A variety of non-surgical techniques is available; however, none is well established. We have used an in-vitro model to show that human gallstones are fragmented readily by shock-wave lithotripsy. Two elderly frail patients with difficult bile-duct stones have been treated successfully by extracorporeal shock-wave lithotripsy. The bile ducts were cleared of stones and the patients suffered no adverse effects. Extracorporeal shock-wave lithotripsy is a new and promising alternative to the current non-surgical techniques for the management of bile-duct stones.

Biliary stent blockage with bacterial biofilm. A light and electron microscopy study.

Clogging of endoscopic stents necessitates their replacement in many patients with malignant obstructive jaundice and limits their use in benign strictures. We studied the basic mechanism of clogging to find ways to prevent it. We did light and electron microscopy studies of blocked and functioning stents, which were prepared so that organic structures would be preserved. The material blocking the lumina was composed of a matrix of bacterial cells and their fibrillar anionic extracellular products. Crystals of calcium bilirubinate, calcium palmitate, and cholesterol were embedded within this matrix. Bacterial cells were attached to the stent surface by a fibrillar matrix, suggesting that the initial event in stent clogging is the development of an adherent bacterial biofilm. Bacterial enzyme activity (beta-glucuronidase and phospholipase) leads to the deposition of crystals. The use of antibacterial plastics in the manufacture of stents may reduce bacterial adhesion and stent clogging.

Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice.

Patients with biliary obstruction due to malignant disease, and judged unfit for open operation, were randomised to have a biliary stent inserted either endoscopically via the papilla of Vater or percutaneously. Analysis after 75 patients had been entered showed that the endoscopic method had a significantly higher success rate for relief of jaundice (81% versus 61%, p = 0.017) and a significantly lower 30-day mortality (15% versus 33%, p = 0.016). The higher mortality after percutaneous stents was due to complications associated with liver puncture (haemorrhage and bile leaks). When stenting is indicated in elderly and frail patients the endoscopic method should be tried first.