Confirmation of intraosseous cannula placement based on pressure measured at the cannula during squeezing the extremity in a piglet model

AIM OF THE STUDY

We sought to assess the reliability of the method using the pressure measured at the intraosseous (IO) cannula while squeezing the involved limb (P(squeezing)) in determining the position of the IO needle and to compare its performance with that of the traditional confirmation method.

METHODS

Eighty limbs of twenty domestic swine were assigned to one of three conditions regarding the position of the IO needle; correct placement (n=40), incorrect placement in which the IO needle was placed into the subcutaneous space without entering the bone (incorrect-subcutaneous placement, n=20), or incorrect placement in which the IO needle passed entirely through the bone (incorrect-penetrating placement, n=20). A blinded investigator randomly identified the position of the needle by the traditional method or test method using P(squeezing). If P(squeezing) was 80 mmHg or higher, the IO cannula was regarded as incorrectly placed.

RESULTS

P(squeezing) was higher in incorrect placements (176.0 mmHg (130.0-195.0)) compared with that in correct placements (27.0 mmHg (20.0-34.0)) (p<0.001). The test method correctly identified all 40 placements, but the traditional method was incorrect for one (5%) of 20 correct placements (p=1.000) and 7 (35%) of 20 incorrect placements (p=0.008). In incorrect placements, false positive results occurred mainly in incorrect-penetrating placements.

CONCLUSION

We suggest that the method using the pressure measured at the IO cannula can be used when there is uncertainty about the position of the IO cannula after determination using traditional methods.

The performances of standard and ResMed masks during bag-valve-mask ventilation

BACKGROUND

A tight mask seal is frequently difficult to obtain and maintain during single-rescuer bag-valve-mask (BVM) ventilation. The ResMed mask (Bella Vista, NSW, Australia) is a continuous-positive-airway-pressure mask (CM) designed for noninvasive ventilation.

OBJECTIVE

In this study, we compared the ventilation performances of a standard mask (SM) and a ResMed CM using a simulation manikin in an out-of-hospital single-rescuer BVM ventilation scenario.

METHODS

Thirty emergency medical technicians (EMTs) performed two 2-minute attempts to ventilate a simulation manikin using BVM ventilation, alternatively, with the SM or the ResMed CM in a randomized order. Ventilation parameters including tidal volume and peak airway pressure were measured using computer analysis software connected to the simulation manikin. Successful volume delivery was defined as delivery of 440-540 mL of tidal volume in accord with present cardiopulmonary resuscitation guidelines.

RESULTS

BVM ventilation using the ResMed CM produced higher mean (± standard deviation) tidal volumes (452 ± 50 mL vs. 394 ± 113 mL, p = 0.014) and had a higher proportion of successful volume deliveries (65.3% vs. 26.7%, p < 0.001) than that using the SM. Peak airway pressure was higher in BVM ventilation using the ResMed CM (p = 0.035). Stomach insufflation did not occur during either method. Twenty-nine of the participants (96.7%) preferred BVM ventilation using the ResMed CM.

CONCLUSIONS

BVM ventilations using ResMed CM resulted in a significantly higher proportion of successful volume deliveries meeting the currently recommended range of tidal volume. Clinical studies are needed to determine the value of the ResMed CM for BVM ventilation.

Potassium induced cardiac standstill during conventional cardiopulmonary resuscitation in a pig model of prolonged ventricular fibrillation cardiac arrest: a feasibility study

AIM OF THE STUDY

Potassium-based cardioplegia has been the gold standard for cardioprotection during cardiac surgery. We sought to evaluate the feasibility and the effects of potassium-induced cardiac standstill during conventional cardiopulmonary resuscitation (CPR) in a pig model of prolonged ventricular fibrillation (VF).

METHODS

VF was induced in 20 pigs, and circulatory arrest was maintained for 14 min. Animals were then resuscitated by standard CPR. Coincident with the start of CPR, 20 ml of saline (control group) or 0.9 mequiv.kg(-1) of potassium chloride diluted to 20 ml (potassium group) was administered into right atrium.

RESULTS

Administration of potassium resulted in asystole lasting for 1.0 min (0.2) in the potassium group animals. VF reappeared in all but one animal, in which wide QRS complex bradycardia followed. Restoration of spontaneous circulation (ROSC) was attained in two animals (20%) in the control group and in seven animals (70%) in the potassium group (p=0.070). Resuscitated animals in the potassium group required fewer countershocks (3, 4 vs. 2 (1-2)), smaller doses of adrenaline (1.84, 1.84 vs. 0.94 (0.90-1.00)mg), and shorter duration of CPR (8, 10 vs. 4.0 (4.0-4.0)min) than did the control group. Potassium concentrations normalised rapidly after ROSC in both groups, and the potassium concentrations at 5 min (5.5, 6.6 vs. 6.8 (6.5-7.8)mequiv.l(-1)) and 4h (4.9, 5.4 vs. 5.9 (5.1-6.4)mequiv.l(-1)) after ROSC were similar in the both groups.

CONCLUSION

In a pig model of untreated VF cardiac arrest for 14 min, resuscitation with potassium-induced cardiac standstill during conventional CPR was found to be feasible.

Gene expression profiling of mouse aborted uterus induced by lipopolysac charide

To identify genes that participate in the abortion process, normal pregnant uteri were compared to lipopolysaccharide (LPS)-induced abortion uteri. At day 6 of pregnancy, mice were treated with LPS at various time points to induce an abortion. Total RNAs were applied to a cDNA microarray to analyze genes with altered expression. At the early stage (2 hours) of LPS-induced abortion, upregulated genes were mainly composed of immune responsive genes, including Ccl4, Ccl2, Cxcl13, Gbp3, Gbp2, Mx2, H2-Eb1, Irf1 and Ifi203. Genes related to toll-like receptor signaling were also overexpressed. At late stages of abortion (12-24 hours), many genes were suppressed rather than activated, and these were mainly related to the extracellular matrix, cytoskeleton, and anti-apoptosis. Altered expression of several selected genes was confirmed by real time reverse transcription-polymerase chain reaction. The results demonstrated that many known genes were altered in the LPS-treated pregnant uterus, implying that the molecular mechanisms of the genes involved in LPS-induced abortion are complicated. Further analysis of this expression profile will help our understanding of the pathophysiological basis for abortion.

Sustained manual abdominal compression during cardiopulmonary resuscitation in a pig model: a preliminary investigation

OBJECTIVES

The present study was undertaken to determine whether sustained manual abdominal compression (SMAC) using left paramedian compression technique can improve coronary perfusion pressure (CPP) during cardiopulmonary resuscitation (CPR) and resuscitation outcomes without causing liver laceration.

METHODS

Ventricular fibrillation was induced in 14 pigs, and circulatory arrest was maintained for 6 min. Animals were resuscitated either by standard CPR (control group) or by standard CPR with SMAC (SMAC-CPR group).

RESULTS

Mean blood pressure, aortic diastolic pressure and right atrial diastolic pressure in the SMAC-CPR group were significantly greater than in the control group throughout simulated basic life support. However, since the increases in aortic and right atrial diastolic pressures were similar, no significant intergroup difference was found in terms of CPP. Return of spontaneous circulation (ROSC) was attained in four of seven animals in the control group and in six of seven animals in the SMAC-CPR group (p = 0.55). Three animals in the control group and four in the SMAC-CPR group survived 24 h after ROSC (p = 1.00). Two of the seven animals in the SMAC-CPR group had a ruptured liver, but no such injury occurred in the control group.

CONCLUSIONS

SMAC using left paramedian compression technique failed to improve CPP during CPR and resuscitation outcomes. Furthermore, this method could not avoid liver laceration.

Variable effects of high-dose adrenaline relative to standard-dose adrenaline on resuscitation outcomes according to cardiac arrest duration

AIM OF THE STUDY

Adjustment of adrenaline (epinephrine) dosage according to cardiac arrest (CA) duration, rather than administering the same dose, may theoretically improve resuscitation outcomes. We evaluated variable effects of high-dose adrenaline (HDA) relative to standard-dose adrenaline (SDA) on resuscitation outcomes according to CA duration.

METHODS

Twenty-eight male domestic pigs were randomised to the following 4 groups according to the dosage of adrenaline (SDA 0.02 mg/kg vs. HDA 0.2mg/kg) and duration of CA before beginning cardiopulmonary resuscitation (CPR): 6 min SDA, 6 min HDA, 13 min SDA, or 13 min HDA. After the predetermined duration of untreated ventricular fibrillation, CPR was provided.

RESULTS

All animals in the 6 min SDA, 6 min HDA, and 13 min HDA groups were successfully resuscitated, while only 4 of 7 pigs in the 13 min SDA group were successfully resuscitated (p=0.043). HDA groups showed higher right atrial pressure, more frequent ventricular ectopic beats, higher blood glucose, higher troponin-I, and more severe metabolic acidosis than SDA groups. Animals of 13 min groups showed more severe metabolic acidosis and higher troponin-I than animals of 6 min groups. All successfully resuscitated animals, except two animals in the 13 min HDA group, survived for 7 days (p=0.121). Neurologic deficit score was not affected by the dose of adrenaline.

CONCLUSION

HDA showed benefit in achieving restoration of spontaneous circulation in 13 min CA, when compared with 6 min CA. However, this benefit did not translate into improved long-term survival or neurologic outcome.

A case of iatrogenic ilio-iliac arteriovenous fistula after percutaneous cardiopulmonary support in a patient with a tortuous iliac artery

Percutaneous cardiopulmonary support (PCPS) has repeatedly been used with success as a tool for resuscitation in various life-threatening emergencies. PCPS-related vascular injuries are common, but ilio-iliac arteriovenous fistula (AVF) formation after PCPS has not been reported so far. We experienced a case of iatrogenic ilio-iliac AVF after PCPS, in which association between iliac artery tortuosity and AVF formation was strongly suspected. This case suggests that the risk of iatrogenic iliac AVF should be considered when PCPS is performed, especially in elderly patients whose arteries are frequently tortuous.

Augmentation of the cooling capacity of refrigerated fluid by minimizing heat gain of the fluid using a simple method of cold insulation

OBJECTIVES

This study was undertaken to determine how rapidly refrigerated fluids gain heat during bolus infusion and to determine whether the refrigerated fluids could be kept cold by a simple cold-insulation method.

METHODS

One liter of refrigerated fluid was run through either a 16-gauge catheter (16G(-) and 16G(+) groups) or an 18-gauge catheter (18G(-) and 18G(+) groups) while monitoring the temperature in the fluid bag and the outflow site. In the 16G(+) and the 18G(+) groups, the fluid bag was placed with an ice pack inside an insulating sleeve during the fluid run.

RESULTS

In the 16G(-) and the 18G(-) groups, the outflow temperature increased to 10-12 degrees C during the fluid run. Meanwhile, outflow temperatures in the 16G(+) and the 18G(+) groups remained below 4.6 and 6.8 degrees C, respectively. The temperatures differed significantly between the 16G(-) and the 16G(+) groups (p < 0.001) and between the 18G(-) and the 18G(+) groups (p < 0.001), respectively.

CONCLUSIONS

Substantial heat gain occurred in the refrigerated fluid even during the relatively short duration of bolus infusion. The heat gain could, however, be easily minimized by cold insulation of the fluid bag.

Caustic injury: can CT grading system enable prediction of esophageal stricture?

BACKGROUND

The aim of this study was to test the utility of our computed tomography (CT) grading system, compared with endoscopy, for association with the development of esophageal stricture in patients with caustic ingestion.

METHODS

This retrospective case series involved 49 patients with caustic ingestion from 1998 to 2009. The degree of esophageal damage was graded using a scoring system based on the extent of esophageal wall edema and the damage in adjacent tissue as seen on thoracoabdominal CT scans. The presence of esophageal stricture was established by esophagography. Diagnostic performance was compared using receiver operating characteristic (ROC) analysis. Sensitivity and specificity were calculated for the grading system.

RESULTS

The CT grading score results showed that grade III was the most common injury (20 cases, 40.8%), followed by grade IV (14 cases, 28.6%), grade II (9 cases, 18.4%), and grade I (6 cases, 12.2%). In addition, damage to the esophagus was significantly correlated with esophageal stricture when the extent of damage approached grades III and IV (p < 0.001). The CT grading system for esophageal stricture resulted in a slightly larger area under the receiver operating characteristic curve (0.90) compared with endoscopic grading system (0.79). The sensitivity and specificity of CT grading system were moderately higher than those of endoscopic grading system.

CONCLUSION

Assessment of the degree of esophageal damage using CT, a noninvasive modality, in patients who visit the emergency department following caustic ingestion should be useful in estimating the occurrence of complications including esophageal stricture.

Distribution and three-dimensional appearance of the interstitial cells of Cajal in the rat stomach and duodenum

The relationship between the interstitial cells of Cajal (ICC) and enteric nerves or smooth muscles cells is not fully defined. Presently, distribution and appearance of ICC in the rat stomach and duodenum was studied by immunohistochemistry, electron microscopy, and three-dimensional reconstruction. c-kit expressing ICC were regularly observed in the Auerbach's myenteric plexus (AP) of the stomach and duodenum. ICC in stomach and duodenum muscle layers was dissimilarly distributed. c-kit immunoreactive cells were sparsely distributed in the stomach circular muscle layer but were abundant in the duodenum deep muscular plexus (DMP). Electron microscopy revealed that stomach ICC-AP were irregular ovals with few cytoplasmic processes, and possessed an electron-dense cytoplasm, numerous mitochondria, intermediate filaments, and caveolae. Duodenum and stomach ICC-AP were similar in appearance. Ultrastructure observations and three-dimensional reconstructions revealed ICC-AP processes wrapping the nerve fibers and projecting into the space between smooth muscle cells. While ICC-AP was occasionally close to enteric nerves or smooth muscle cells, no connections were observed. ICC-DMP in duodenum was elongated and adopted the same cell axis orientation as the circular muscle cells. Unlike ICC-AP, ICC-DMP formed gap junctions with smooth muscle cells and had close contact with nerves. These results indicate that ICC-AP is regularly distributed in stomach and duodenum, while ICC-DMP is exclusively located in the duodenum. ICC-DMP, which possess gap junctions and closely contacts nerves, may participate in neuromuscular transmission.

Rapidly induced selective cerebral hypothermia using a cold carotid arterial flush during cardiac arrest in a dog model

PURPOSE

The present study was undertaken to determine whether flushing the carotid artery with normal saline at 4 degrees C (hypothermic carotid arterial flush, HCAF) during cardiac arrest can achieve selective cerebral hypothermia rapidly during cardiac arrest and improve cerebral outcome.

METHODS

Ventricular fibrillation (VF) was induced in fourteen dogs and circulatory arrest was maintained for 9 min. Dogs were then resuscitated by cardiopulmonary resuscitation. The dogs were divided into two groups; a control group (n=7), which underwent precisely the same procedure as the experimental group but not HCAF, and an experimental group (HCAF group; n=7), which received HCAF from 8 min after the onset of VF.

RESULTS

Two dogs in the control group and in the HCAF group died within 72 h after the recovery of spontaneous circulation (ROSC) due to extracerebral complications. The remaining 10 dogs survived to final evaluation at 72 h post-ROSC. In the HCAF group, tympanic temperature decreased from 37.7 degrees C (37.5-37.8) to 34 degrees C in 1 min (1-1.5) from the start of HCAF and was maintained below 34 degrees C until 6.5 min (3-12) after the start of HCAF, whereas oesophageal and rectal temperatures were maintained above 35 degrees C. Neurological deficit scores (0-100%) at 72 h post-ROSC were 42.4% (27.0-80.6) in the control group and 18.4% (14.0-36.0) in the HCAF group (p<0.05).

CONCLUSION

HCAF induced selective cerebral hypothermia rapidly during cardiac arrest and improved neurological deficit scores after 9 min of no blood flow in the described canine cardiac arrest model.

Hemorrhagic gastritis and gas emboli after ingesting 3% hydrogen peroxide

It is well known that ingestion of low concentrations of hydrogen peroxide is usually nontoxic; this does not produce gas embolism and is only a mild irritant to the gastrointestinal tract. We report the case of a 25-year-old woman who ingested one mouthful of 3% hydrogen peroxide and presented to the Emergency Department with persistent vomiting and epigastric pain. The radiographic evaluation found portal venous gas emboli. In addition, upper gastrointestinal endoscopy performed 2 h after ingestion revealed diffuse hemorrhagic gastritis. She showed a decrease of hemoglobin concentration and a positive test result for occult blood in stool. She was observed for 14 days and discharged. Follow-up endoscopy showed erythematous gastritis. This case illustrates that a low concentration of hydrogen peroxide can cause portal venous gas embolism and severe gastrointestinal injuries even if only a small amount is ingested.

Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn's disease

BACKGROUND AND STUDY AIMS

Intestinal tuberculosis and Crohn's disease are chronic inflammatory bowel disorders that are difficult to differentiate from one another. This study aimed to evaluate the diagnostic value of various colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn's disease.

PATIENTS AND METHODS

Colonoscopic findings on initial work-up were prospectively recorded in patients with an initial diagnosis of either intestinal tuberculosis or Crohn's disease. These findings were analyzed after a final diagnosis of intestinal tuberculosis (n = 44) or Crohn's disease (n = 44) had been made after follow-up.

RESULTS

Four parameters (anorectal lesions, longitudinal ulcers, aphthous ulcers, and cobblestone appearance) were significantly more common in patients with Crohn's disease than in patients with intestinal tuberculosis. Four other parameters (involvement of fewer than four segments, a patulous ileocecal valve, transverse ulcers, and scars or pseudopolyps) were observed more frequently in patients with intestinal tuberculosis than in patients with Crohn's disease. We hypothesized that a diagnosis of Crohn's disease could be made when the number of parameters characteristic of Crohn's disease was higher than the number of parameters characteristic of intestinal tuberculosis, and vice versa. Making these assumptions, we calculated that the diagnosis of either intestinal tuberculosis or Crohn's disease would have been made made correctly in 77 of our 88 patients (87.5 %), incorrectly in seven patients (8.0 %), and would not have been made in four patients (4.5 %).

CONCLUSIONS

A systematic analysis of colonoscopic findings is very useful in the differential diagnosis between intestinal tuberculosis and Crohn's disease.

Primary colon lymphoma in Korea: a KASID (Korean Association for the Study of Intestinal Diseases) Study

Although almost all primary colorectal lymphomas are of B-cell lineage in Western countries, primary colorectal T-cell lymphomas are not uncommon in the East. The aim of this study was to review the clinical characteristics and treatment outcomes of primary colorectal lymphomas, with special emphasis on the differences between T-cell and B-cell lymphomas. Ninety-five cases of primary colorectal lymphomas that satisfied Dawson's criteria were identified from the clinical databases of 13 university hospitals in Korea. The mean age at the time of presentation was 51.1 years and the male:female ratio was 64:31. The clinical information, including endoscopic and histological characteristics, was retrospectively analyzed. Of the primary colorectal lymphomas, 78 cases (82.1%) were of B-lineage and 17 cases (17.9%) were of T-cell lineage. Patients with T-cell lymphomas presented at a younger age than patients with B-cell lymphomas (42.8 vs 52.9 years, respectively; P = 0.016). The most common presenting symptom was abdominal pain (87.1%) for B-cell lymphomas, whereas hematochezia or night fever was more common for T-cell lymphomas (52.9% and 35.3%, respectively). The most common endoscopic type was fungating mass (54.0%) for B-cell lymphomas and ulcerative/ulcero-infiltrative lesions (80.0%) for T-cell lymphomas. Intussusception was more common in B-cell lymphomas than in T-cell lymphomas (30.8% vs 5.9%, respectively; P = 0.035), but perforation was more common in T-cell lymphomas than in B-cell lymphomas (23.5% vs 3.8%, respectively; P = 0.005). The prognosis was significantly worse for T-cell lymphomas than for B-cell lymphomas (P = 0.002). Primary colorectal T-cell lymphomas are characterized by multifocal ulcerative lesions in relatively young patients, a high rate of hematochezia, fever, or perforation, and a poor prognosis even for cases of localized disease.

Accuracy of magnetic resonance cholangiopancreatography for locating hepatolithiasis and detecting accompanying biliary strictures

BACKGROUND AND STUDY AIMS

Magnetic resonance cholangiopancreatography (MRCP) is rapidly replacing diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in various pancreaticobiliary diseases. This study was designed to evaluate the accuracy of MRCP in detection of hepatolithiasis and accompanying biliary strictures.

PATIENTS AND METHODS

A prospective study over 2 years was conducted in 66 patients with primary intrahepatic stones. All patients with hepatolithiasis underwent percutaneous transhepatic cholangioscopy (PTC) within 2 weeks of the MRCP examination. The MRCP findings were compared with those of PTC as the reference standard for assessing the location of intrahepatic stones and the presence or absence of accompanying biliary strictures.

RESULTS

The sensitivity, specificity, and accuracy of MRCP for detecting and locating intrahepatic stones were 97 %, 99 %, and 98 %, respectively. The sensitivity, specificity, and accuracy of MRCP for detecting and locating intrahepatic bile duct strictures were 93 %, 97 %, and 97 %, respectively. During PTC, six of the 66 patients (9 %) were found on histology to have intraductal cholangiocarcinoma in stone-bearing ducts, which had not been suspected on MRCP.

CONCLUSIONS

In this study, MRCP allowed intrahepatic stones and accompanying biliary strictures to be located accurately. MRCP may therefore be able to replace diagnostic ERCP in patients with primary intrahepatic stones. However, MRCP had a limited ability to reveal concurrent intraductal cholangiocarcinoma associated with hepatolithiasis.

Atypical endoscopic features of rectal carcinoids

BACKGROUND AND STUDY AIMS

It is not normally difficult to diagnose carcinoid tumors (well-differentiated endocrine neoplasms) of the rectum endoscopically, as they usually have a characteristic appearance. However, little is known about the atypical endoscopic findings in some rectal carcinoids and the present study was performed to analyze these.

PATIENTS AND METHODS

The endoscopic findings in 67 consecutive patients with rectal carcinoids (37 men, 30 women; age range 23 - 76) were analyzed retrospectively.

RESULTS

Tumor size ranged from 2 mm to 30 mm (average 7.4 mm). Of the 67 patients, 52 (78 %) displayed the characteristic endoscopic findings of smooth, round, sessile elevations covered with normal-appearing or yellow-discolored mucosa; in 15 (22 %) there were one or more atypical endoscopic findings. These included a semipedunculated appearance (n = 6), hyperemia (n = 5), a central depression (n = 6), erosion (n = 5), and ulceration (n = 4). Atypical findings were noted in none of 20 carcinoids &lambda< 5 mm in diameter; in six (20 %) of the 30 carcinoids between 5 mm and 9 mm; in six (43 %) of the 14 carcinoids between 10 mm and 19 mm; and in three (100 %) of the three carcinoids >/= 20 mm in diameter ( P < 0.001). Invasion into the muscularis propria or metastasis to the liver or lymph nodes occurred in three of the four patients with ulceration, but it was confirmed in only one of the 63 patients without ulceration ( P < 0.001).

CONCLUSIONS

Atypical endoscopic appearances of rectal carcinoids are observed more frequently as the size of the tumor increases and a finding of ulceration may have a prognostic value.

The antioxidant effect of rebamipide on oxygen free radical production by H. pylori-activated human neutrophils: in comparison with N-acetylcysteine, ascorbic acid and glutathione

Helicobacter pylori(H. pylori)-activated neutrophils produce the oxygen-derived free radicals (OFRs) which play an important role in gastric mucosal cell damage. Rebamipide (2-(4-chlorobenzoylamino)-3-[2-(1H)-quinolinon-4-yl] propionic acid) is an antiulcer compound, which protects gastric mucosa against OFR-mediated injury. In order to investigate the effects of rebamipide on OFR production and to compare the antioxidant activity of rebamipide with those of three known antioxidants, N-acetylcysteine (AC), ascorbic acid (Vit C) and glutathione (GSH), the antioxidant activities were determined by luminol-dependent chemiluminescence (ChL) assay and pyrogallol autoxidation assay. The ChL value was markedly elevated immediately after the addition of H. pylori into the medium containing neutrophils. The antioxidant activity of 1.0 mM rebamipide was greater than that of 0.1 mM rebamipide in the luminol-dependent ChL assay, while in the pyrogallol autoxidation assay, the antioxidant activity of 1.0 mM rebamipide was similar to that of 0.1 mM rebamipide. Rebamipide inhibited OFR generation in the pyrogallol autoxidation assay, with the potency being in the order of GSH > Vit C > rebamipide > AC. In the luminol-dependent ChL assay, the antioxidant activity of rebamipide was the greatest among them. These results indicate that rebamipide is a potent antioxidant and scavenges OFRs produced by H. pylori effectively in luminol-dependent ChL assays.

Incomplete pancreas divisum: is it merely a normal anatomic variant without clinical implications?

BACKGROUND AND STUDY AIMS

Incomplete pancreas divisum (PD) has been generally regarded as merely a normal anatomic variant, without clinical implications. This study compares the prevalence, symptom occurrence rate, clinical presentation, and outcomes of endoscopic treatment in patients with incomplete PD and those with complete PD.

PATIENTS AND METHODS

The study population consisted of 56 patients (27 with complete PD and 29 with incomplete PD), identified from 4473 newly performed endoscopic retrograde cholangiopancreatography examinations. Endoscopic treatment (minor papilla sphincterotomy with stents or nasopancreatic drainage tube insertion) was attempted in 25 symptomatic patients with PD, which was suspected to be causing the associated pancreatic diseases: acute recurrent pancreatitis (ARP) (n = 13; five patients with complete PD and eight with incomplete PD); chronic pancreatitis (CP) (n = 10: five patients with complete PD and five with incomplete PD); and pancreatic-type pain (PP) (n = 2; one patient with complete PD and one with incomplete PD). The mean follow-up period was 17 months (range 9 - 49 months).

RESULTS

In 12 of the 27 patients with complete PD--six with ARP, five with CP, and one with PP--it was suspected that PD was the cause of pancreatic disease. Ten of the 11 symptomatic patients with complete PD underwent successful endoscopic treatment (five with endoscopic minor papilla sphincterotomy and stenting, and five with endoscopic minor papilla sphincterotomy and endoscopic nasopancreatic drainage), and seven of these ten patients benefited from the endoscopic treatment. In 14 of the 29 patients with incomplete PD--eight with ARP, five with CP, and one with PP--it was suspected that pancreas divisum was the cause of pancreatic disease. Thirteen of the 14 symptomatic patients with incomplete PD underwent successful endoscopic treatments (six with endoscopic minor papilla sphincterotomy and stenting, and seven with endoscopic minor papilla sphincterotomy and endoscopic nasopancreatic drainage), and eight of these 13 patients experienced clinical improvement.

CONCLUSIONS

The prevalence rate, symptom occurrence rate, clinical presentation, and outcomes of endoscopic treatment were similar in patients with complete PD and incomplete PD. Incomplete PD may therefore have similar clinical implications to those of complete PD.

Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy

BACKGROUND

Endoscopic biliary sphincterotomy (EST) is a well-established procedure for bile duct stone extraction. Bile duct stones can be classified as primary or secondary. However, few data are available on the recurrence of primary and secondary bile duct stones after EST. Therefore risk factors for the recurrence of primary bile duct stones after EST were prospectively studied.

METHODS

Between 1991 and 1997, 61 patients underwent EST for primary bile duct stones. All met the following criteria: (1) previous cholecystectomy without bile duct exploration, (2) detection of bile duct stones at least 2 years after initial cholecystectomy. Mean follow-up was 2.2 years. Fourteen patients were lost to follow-up. The recurrence of primary bile duct stones was defined as the detection of bile duct stones no sooner than 6 months after complete clearance of primary bile duct stones.

RESULTS

The overall recurrence rate of primary bile duct stones was 21% (10 of 47). Two significant risk factors for recurrence were identified by multivariate analysis: (1) patients with a bile duct diameter of 13 mm or greater after stone removal had recurrences more frequently than those with a duct diameter of 13 mm or less, and (2) patients whose papilla was located on the inner rim or deep within a diverticulum, so that the papillary orifice was not visible endoscopically, had more frequent recurrences than patients with a papilla outside the diverticulum, or no peripapillary diverticulum.

CONCLUSION

The independent risk factors for recurrence of primary bile duct stones were sustained dilation of the bile duct even after complete removal of stones and location of the papilla on the inner rim or deep within a diverticulum.

Radiologic findings of Behçet syndrome involving the gastrointestinal tract

Behçet syndrome is characterized by the histopathologic finding of nonspecific vasculitis in multiple organs. The diagnosis is usually made on the basis of the combination of clinical signs and symptoms. This disease involves the gastrointestinal tract in 10%-50% of patients, and the terminal ileum and cecum are chiefly affected. Barium study is useful in demonstrating the characteristic radiographic features of Behçet syndrome involving the gastrointestinal tract. The presence of deep, penetrating ulcers results in a high rate of complications, such as perforation, fistula, hemorrhage, and peritonitis. Furthermore, recurrence of disease adjacent to or at the surgical anastomosis is common. Computed tomography is useful in determining the extent of the lesions and in identifying cases in which complications are likely to occur. Familiarity with the various radiologic findings of Behçet syndrome involving the gastrointestinal tract helps in making an early diagnosis, as well as in establishing an appropriate treatment strategy.