Hemoglobin Sherwood Forest detected by high performance liquid chromatography for hemoglobin A1c

Hb Sherwood Forest has been so far identified in only one patient in 1977. This study describes the second detection of this hemoglobin variant by routine high performance liquid chromatography (HPLC) in a diabetic patient and her healthy grand niece. In both, glycosylated hemoglobin (HbA1c) values were excessively elevated (52%), as determined by HPLC with a cation exchange column. The latex agglutination test showed values of HbA1c in the expected normal range. Citrate agar electrophoresis revealed a hemoglobin variant with a mobility similar to HbF. Amino acid analysis and DNA sequence analysis revealed an Arg-->Thr exchange at codon 104 of the beta-chain. This sequence has been described as Hb Sherwood Forest in 1977. The hemoglobin variant is clinically silent and might be confused with excessively high HbA1c in routine measurement of glycosylated hemoglobin.

Laparoscopic diagnosis of peritoneal serous papillary carcinoma

Peritoneal serous papillary carcinoma is a rare primary tumor of the peritoneum. We report here a case diagnosed by laparoscopy, and summarize the clinicopathological features previously reported in patients with this tumor. Laparoscopy was performed in a 66-year-old woman with high-protein ascites and a three-month history of lower abdominal pain. Macroscopically, the parietal and visceral peritoneum was studded with prominent white nodules up to 5 mm in diameter. Multiple biopsies revealed a tubulopapillary serous adenocarcinoma. After exclusion of metastatic peritoneal carcinomatosis (especially ovarian cancer) and malignant mesothelioma, the diagnosis of peritoneal serous papillary carcinoma was established. The patient was placed on chemotherapy (first-line: 5-fluorouracil, adriamycin, and mitomycin C; second-line: paclitaxel). She died 22 months after diagnosis. The present case is also remarkable for the coexistence of granulomatous peritonitis overshadowing the malignant nature of the process. This case report emphasizes the importance of laparoscopy with multiple biopsies in the workup of undetermined exudative ascites.

Prevalence of Helicobacter pylori antibodies in the serum of gastroenterologists in Austria

Eighty-eight endoscopists (mean age 41 years, range 29-76 years) and a control group of 100 persons of similar ages were investigated for the prevalence of antibodies (ABs) to Helicobacter pylori, using a quantitative enzyme-linked immunosorbent assay (ELISA) to IgG, two semiquantitative ELISAs to IgG and IgA, and a latex test to IgG and IgM antibodies. The prevalence of antibodies to H. pylori in endoscopists was 48% (quantitative ELISA), 56% (semiquantitative ELISA to IgG), 62% (latex test), and 57% by combined evaluation of semiquantitative ELISAS to IgG and IgA. The respective numbers in the control group were 47%, 48%, 48% and 51%. None of the differences was significant. In both groups, endoscopists and controls, there was a significantly higher H. pylori positivity in older subjects compared to younger persons, but there was no difference between the two groups. The prevalence of ABs was independent to the number of endoscopies previously performed, and independent of protective measures taken, such as wearing gloves during the procedures. Antibody titers as measured with quantitative ELISA showed a positive correlation with the length of time the subject had been active as an endoscopist, but no correlation with the total number of endoscopies performed. In conclusion, the prevalence of ABs to H. pylori in endoscopists follows the age-dependent pattern known from the general population. The regular performance of gastrointestinal endoscopies poses no additional risk of infection with H. pylori in Austria.

[Ultrasound controlled extracorporeal shockwave lithotripsy of pancreatic calculi in patients with chronic recurrent pancreatitis]

A consecutive series of 10 patients with pancreatic stones due to chronic pancreatitis was treated by extracorporeal shockwave lithotripsy during an investigation period of 2 years. The first step of the therapeutic regime included an endoscopic sphincterotomy prior to shockwave treatment. The targeting procedure was performed strictly under sonographic control. All patients were treated with a second-generation electrohydraulic lithotriptor, fragmentation could be achieved in all 10 cases. In 7 patients stonefreeness could be reached by endoscopic stone extraction, all these patients were symptom-free over a follow-up period of 12 months. In 3 patients complete duct clearance could not be achieved, these patients presented with minor symptoms over the follow-up period.

[A 41-year-old woman with recurrent cholangitis after bile duct operation 17 years earlier. A case report]

The case of an 41 year old female is reported, who underwent surgical correction of a congenital cyst of the common bile duct 17 years ago. Because of repeated pain attacks in the right upper quadrant in connection with fever and serochemical signs of cholestasis the patient was admitted to our unit. The exploration with ERCP and CT now showed a common channel in combination with a congenital cyst of the common bile duct. The risk of the anomalous pancreaticobiliary junction upon either the biliary tract or the pancreatic duct will be discussed, also the fact of an higher incidence of malignant tumors of the biliary system. The therapeutic procedures will be discussed.

Agenesis of the dorsal pancreas in a woman with diabetes mellitus and in both of her sons

Complete agenesis of the dorsal pancreas has rarely been described. Complete agenesis of the dorsal pancreas in a female who developed insulin-dependent diabetes mellitus at the age of 39 years is reported. The diagnosis of agenesis of the dorsal pancreas was suspected by abdominal ultrasound and confirmed by abdominal computed tomography (CT), magnetic resonance imaging, and endoscopic retrograde pancreatography. Her exocrine pancreatic function was essentially normal. Both of the patient's sons also had agenesis of the body and tail of the pancreas verified by abdominal CT but had no evidence of diabetes mellitus. This familial occurrence of agenesis of the dorsal pancreas suggests that hereditary mechanisms may play a role in the pathogenesis of this anomaly.

[Extracorporeal shockwave therapy in giant stones in the common bile duct--a case report]

A huge common bile duct stone of 6 to 3 cm in diameter in a 64 year old lady was approached by ESWL, after endoscopic therapy such as mechanical lithotripsy and removal with the Dormia basket had failed because of the extraordinary size of this stone. A surgical therapy was not possible because of pronounced vascular and cardiopulmonary risk, so ESWL was applied to this patient. The stone was fragmented in two sessions of ESWL under sonographic targeting and the fragments were removed endoscopically. After one month one fragment still remained in the common bile duct, which then was removed also endoscopically. Two months later the ERC showed a stone-free common bile duct. This case demonstrates, that even common bile duct stones of extraordinary size can be removed by combining ESWL with endoscopic techniques. Following the trend to minimally invasive therapy, sonography should be preferred over XRay in diagnosis before ESWL as well as during ESWL.

[Cowden syndrome]

A patient with multiple hamartoma syndrome or Cowden's disease with multiple gastrointestinal polyps and malignant melanoma is presented. The syndrome is characterized by hamartomatous tumors of the skin, fibrocystic disease of the breasts, gastrointestinal polyps and disease of the thyroid gland such as goiter and adenoma. In addition, other abnormalities and malformations occur in the skeletal system, central nervous system and urogenital tract. Recognition of this syndrome is important because of the association with malignant tumors of the breast and thyroid gland and with malignant melanoma. Gastrointestinal hamartomatous polyps may lead to the diagnosis of Cowden's disease which must be separated from other intestinal polyposis syndromes.

[Sonography and cytology of cold thyroid nodules]

270 patients with a scintigraphically cold thyroid nodule of sonographically increased (n = 34), diminished (n = 72) or neutral (n = 86) echogenity or cystic criteria (n = 78) were subjected to fine needle aspiration biopsy. This revealed unequivocal malignancy in 8 and follicular neoplasia in another 30 patients, 10 of whom proved to have malignomas on further evaluation. A total of 12 papillary and 2 follicular carcinomas, 2 non-Hodgkin lymphomas, 1 sarcoma and the metastasis of a breast carcinoma were diagnosed. The most sensitive criteria for malignancy were diminished echogenity, an inhomogeneous echo pattern and the occurrence of a solitary nodule. The incidence of malignancy was increased among males but not among especially young persons. There was no sonographic feature that would permit omission of fine needle aspiration.

[Pathologic enzyme patterns in sonographically verified liver metastases]

The serum enzyme pattern, consisting of GOT, GPT, lactate dehydrogenase, gamma glutamyl transpeptidase and alkaline phosphatase, was investigated in 128 patients with sonographically verified liver metastases. Gamma glutamyl transpeptidase and alkaline phosphatase turned out to be the most sensitive enzymes, being elevated in 89% and 88%, respectively. The GOT was elevated in 45% GPT in 37.5% and lactate dehydrogenase in 56% of all cases. The enzyme elevation did not correlate with the degree of liver involvement. In conclusion, pathological serum enzyme patterns are useful for the detection and follow up of liver metastases. Normal serum enzyme levels do not rule out the presence of liver metastases.

[Sonographic comparative studies of the portal vascular system before and following endoscopic sclerosing of esophageal varices]

On the occasion of 35 episodes of oesophageal injection therapy in which partly the intravascular and partly the perivascular injection technique were used, real time sonographic measurements were performed on the veins of the portal system immediately before and after sclerotherapy. In the case of intravascular injection, both the portal and the splenic vein and the confluens of the splenic and the superior mesenteric vein showed an increase in diameter, whereas in the cases of perivascular injection such changes were minimal or absent. The practical applicability of such sonographic calibrations could possibly lie in certain conclusions that could be drawn concerning the degree of vascular compression or obliteration during each session of sclerotherapy.