Endoscopically assisted minimally invasive surgery for gallstones

BACKGROUND

We present a case report of Bouveret syndrome followed by a review of the recent literature regarding the management of this condition. Bouveret syndrome is a form of gastric outlet obstruction secondary to a gallstone which has eroded through the gallbladder into the duodenum. It is an uncommon variant of gallstone ileus. Endoscopic methods have been described to extract the stone from the duodenum.

METHODS

This is a case of an 85-year-old female patient who presented with a 1-week history of nausea, intermittent bilious vomiting and anorexia. Imaging confirmed the diagnosis of Bouveret syndrome caused by two large gallstones. Conventional endoscopic methods successfully extracted the impacted stones from the duodenum into the stomach but were unable to extract the stones from the stomach. A mini-transverse laparotomy and gastrotomy were performed to finally extract the stones.

Lack of hepatocellular CD10 along bile canaliculi is physiologic in early childhood and persistent in Alagille syndrome

Many tissues, including hepatobiliary cells, express neutral endopeptidase (CD10), encoded by MME. Serum neutral endopeptidase activity (NEA) has been recommended as a marker of cholestasis in adults but not in children with Alagille syndrome (AGS). We investigated ontogenic and disease-related differences in the expression of CD10. CD10 was found on canalicular surfaces of hepatocytes throughout the lobule in 16 adults and in 31 children aged > or =24 months, with and without cholestasis, but not in 39 children aged <24 months, with and without cholestasis. Ten AGS children aged 2 months to 6 years lacked any canalicular CD10 expression. Cholangiocyte apices and/or intrasinusoidal granulocytes marked for CD10 in all subjects. Liver membrane fractions from a child with cholestasis aged <24 months and from 2 AGS patients aged >24 months contained reduced levels of CD10. In contrast, AGS children and all controls expressed CD10 similarly on granulocytes. MME mRNA was found in the liver of children aged <24 months and of adults, all with cholestasis, and of AGS patients. Granulocyte MME mRNA levels were similar among all study subjects; however, liver MME mRNA levels were 6- to 140-fold less than in normal adults in all cholestatic subjects, including AGS children. Methylation of the MME promoter was not detected in the liver of AGS children. In conclusion, hepatocytes in early childhood physiologically lack immunohistochemically detectable CD10. Reduced MME mRNA in AGS is not due to MME promoter methylation. Liver CD10 in childhood appears to undergo reduced synthesis or rapid degradation, which persists in AGS. Absence of CD10 expression thus may limit NEA as a marker of cholestasis in young patients and in AGS.

Pneumobilia following blunt abdominal trauma

BACKGROUND

Pneumobilia is the presence of gas within the biliary tree. It is an important diagnostic sign in spontaneous biliary enteric fistulae, classically in gallstone ileus. There are a number of other causes including surgically created biliary enteric fistula, instrumentation of the bile duct at endoscopic retrograde cholangiopancreatography, emphysematous cholecystitis and pyogenic cholangitis. Pneumobilia has also been reported following blunt abdominal trauma. The significance of isolated pneumobilia following abdominal trauma has not been conclusively established.

METHODS

We present a patient with traumatic pneumobilia following blunt trauma to the abdomen which was managed conservatively.

CONCLUSION

Pneumobilia following blunt abdominal trauma is not an absolute indication for laparotomy.

Mutations in bile salt export pump (ABCB11) in two children with progressive familial intrahepatic cholestasis and cholangiocarcinoma

Fatal peripheral cholangiocarcinoma developed in 2 girls with progressive familial intrahepatic cholestasis, ABCB11 mutations, and absent bile salt export pump (BSEP) expression. BSEP deficiency may cause cholangiocarcinoma through bile-composition shifts or bile-acid damage within cells capable of hepatocytic/cholangiocytic differentiation. This observation suggests the need for hepatobiliary-malignancy surveillance and early consideration for liver transplantation.

A rotenone-sensitive site and H2O2 are key components of hypoxia-sensing in neonatal rat adrenomedullary chromaffin cells

In the perinatal period, adrenomedullary chromaffin cells (AMC) directly sense PO2 and secrete catecholamines during hypoxic stress, and this response is lost in juvenile ( approximately 2 week-old) chromaffin cells following postnatal innervation. Here we tested the hypothesis that a rotenone-sensitive O2-sensor and ROS are involved in the hypoxic response of AMC cultured from neonatal and juvenile rats. In whole-cell recordings, hypoxia (PO2=5-15 mm Hg) inhibited outward current in neonatal AMC; this response was reversed by exogenous H2O2 and mimicked and occluded by intracellular catalase (1000 units/ml), as well as the antioxidants, N-acetyl-L-cysteine (NAC; 50 microM) and Trolox (200 microM). Acute hypoxia decreased ROS levels and stimulated ATP secretion in these cells, as measured by luminol and luciferin-luciferase chemiluminescence, respectively. Of several mitochondrial electron transport chain (ETC) inhibitors tested, only rotenone, a complex I blocker, mimicked and occluded the effects of hypoxia on outward current, cellular ROS, and ATP secretion. Succinate donors, which act as complex II substrates, reversed the effects of hypoxia and rotenone in neonatal AMC. In contrast, in hypoxia-insensitive juvenile AMC, neither NAC nor rotenone stimulated ATP secretion though they both caused a decrease in ROS levels. We propose that O2-sensing by neonatal AMC is mediated by decreased ROS generation via a rotenone-sensitive site that is coupled to outward current inhibition and secretion. Interestingly, juvenile AMC display at least two modifications, i.e. an uncoupling of the O2-sensor from ROS regulation, and an apparent insensitivity of outward current to decreased ROS.

Spinor dynamics-driven formation of a dual-beam atom laser

We demonstrate a novel dual-beam atom laser formed by outcoupling oppositely polarized components of an all-optical F = 1 spinor Bose-Einstein condensate whose Zeeman sublevel populations have been coherently evolved through spin dynamics. The condensate is formed through all-optical means using a single-beam running-wave dipole trap. We create a condensate in the magnetic field-insensitive m(F) = 0 state, and drive coherent spin-mixing evolution through adiabatic compression of the initially weak trap. Such dual beams, number-correlated through the angular momentum-conserving reaction 2m(0) ?m(+1) +m(-1), have been proposed as tools to explore entanglement and squeezing in Bose-Einstein condensates, and have potential use in precision phase measurements.

Sinistral portal hypertension

Sinistral, or left-sided, portal hypertension is a rare cause of upper gastrointestinal haemorrhage. There are many causes of sinistral portal hypertension. The primary pathology usually arises in the pancreas and results in compression of the pancreatic vein. This compression causes backpressure in the left portal venous system and subsequent gastric varices. Management is usually surgical to treat the underlying pathology and splenectomy to decompress the left portal venous system. This paper presents four cases of sinistral portal hypertension followed by a literature review of the reported causes and management issues.

Hepatocellular carcinoma in ten children under five years of age with bile salt export pump deficiency

Hepatocellular carcinoma (HCC) is rare in young children. We attempted to see if immunohistochemical and mutational-analysis studies could demonstrate that deficiency of the canalicular bile acid transporter bile salt export pump (BSEP) and mutation in ABCB11, encoding BSEP, underlay progressive familial intrahepatic cholestasis (PFIC)--or "neonatal hepatitis" suggesting PFIC--that was associated with HCC in young children. We studied 11 cases of pediatric HCC in the setting of PFIC or "neonatal hepatitis" suggesting PFIC. Archival liver were retrieved and immunostained for BSEP. Mutational analysis of ABCB11 was performed in leukocyte DNA from available patients and parents. Among the 11 nonrelated children studied aged 13-52 months at diagnosis of HCC, 9 (and a full sibling, with neonatal hepatitis suggesting PFIC, of a tenth from whom liver was not available) had immunohistochemical evidence of BSEP deficiency; the eleventh child did not. Mutations in ABCB11 were demonstrated in all patients with BSEP deficiency in whom leukocyte DNA could be studied (n = 7). These mutations were confirmed in the parents (n = 14). With respect to the other 3 children with BSEP deficiency, mutations in ABCB11 were demonstrated in all 5 parents in whom leukocyte DNA could be studied. Thirteen different mutations were found. In conclusion, PFIC associated with BSEP deficiency represents a previously unrecognized risk for HCC in young children. Immunohistochemical evidence of BSEP deficiency correlates well with demonstrable mutation in ABCB11.

VPS33B mutation with ichthyosis, cholestasis, and renal dysfunction but without arthrogryposis: incomplete ARC syndrome phenotype

Arthrogryposis-renal dysfunction-cholestasis (ARC) syndrome is a rare multisystem disorder first described in 1979 and recently ascribed to mutation in VPS33B, whose product acts in intracellular trafficking. Arthrogryposis, spillage of various substances in the urine, and conjugated hyperbilirubinemia define an ARC core phenotype, in some patients associated with ichthyosis, central nervous system malformation, deafness, and platelet abnormalities. We describe a patient with cholestasis, aminoaciduria, ichthyosis, partial callosal agenesis, and sensorineural deafness who, although homozygous for the novel VPS33B mutation 971delA/K324fs, predicted to abolish VPS33B function, did not exhibit arthrogryposis. The phenotypes associated with VPS33B mutation may include incomplete ARC.

The development of the quartz crystal oscillator industry of World War II

This paper offers a history of a critical episode in military and electronics history-the difficult creation of quartz crystal frequency control units for radio communications during World War II. As a means of controlling the frequencies of radio transmitters and receivers, amateur radio hobbyists quickly accepted the quartz crystal oscillator after its initial development in the late 1920s. The military, however, declined to adopt this technology until just prior to World War II. Due to the small market for crystal oscillators, no mass production industry had ever developed to produce this extremely high precision electronic component. As war engulfed the nation, the U.S. Army Signal Corps found itself in the dangerous position of having gambled the integrity of its communications equipment on a component that could not possibly be produced in the quantities immediately needed. This paper looks at the challenges the United States faced in building a crystal manufacturing capability and in supplying this industry with sufficient supplies of raw quartz. A fairly specialized component of communications technology emerged from spare beginnings in prewar amateur radio to become the very foundation of a wide range of electronic devices today.

Characterization of mutations in ATP8B1 associated with hereditary cholestasis

Progressive familial intrahepatic cholestasis (PFIC) and benign recurrent intrahepatic cholestasis (BRIC) are clinically distinct hereditary disorders. PFIC patients suffer from chronic cholestasis and develop liver fibrosis. BRIC patients experience intermittent attacks of cholestasis that resolve spontaneously. Mutations in ATP8B1 (previously FIC1) may result in PFIC or BRIC. We report the genomic organization of ATP8B1 and mutation analyses of 180 families with PFIC or BRIC that identified 54 distinct disease mutations, including 10 mutations predicted to disrupt splicing, 6 nonsense mutations, 11 small insertion or deletion mutations predicted to induce frameshifts, 1 large genomic deletion, 2 small inframe deletions, and 24 missense mutations. Most mutations are rare, occurring in 1-3 families, or are limited to specific populations. Many patients are compound heterozygous for 2 mutations. Mutation type or location correlates overall with clinical severity: missense mutations are more common in BRIC (58% vs. 38% in PFIC), while nonsense, frameshifting, and large deletion mutations are more common in PFIC (41% vs. 16% in BRIC). Some mutations, however, lead to a wide range of phenotypes, from PFIC to BRIC or even no clinical disease. ATP8B1 mutations were detected in 30% and 41%, respectively, of the PFIC and BRIC patients screened.

Mutations in VPS33B, encoding a regulator of SNARE-dependent membrane fusion, cause arthrogryposis-renal dysfunction-cholestasis (ARC) syndrome

ARC syndrome (OMIM 208085) is an autosomal recessive multisystem disorder characterized by neurogenic arthrogryposis multiplex congenita, renal tubular dysfunction and neonatal cholestasis with bile duct hypoplasia and low gamma glutamyl transpeptidase (gGT) activity. Platelet dysfunction is common. Affected infants do not thrive and usually die in the first year of life. To elucidate the molecular basis of ARC, we mapped the disease to a 7-cM interval on 15q26.1 and then identified germline mutations in the gene VPS33B in 14 kindreds with ARC. VPS33B encodes a homolog of the class C yeast vacuolar protein sorting gene, Vps33, that contains a Sec1-like domain important in the regulation of vesicle-to-target SNARE complex formation and subsequent membrane fusion.

Progressive familial intrahepatic cholestasis, type 1, is associated with decreased farnesoid X receptor activity

BACKGROUND & AIMS

The mechanisms by which mutations in the familial intrahepatic cholestasis-1 gene cause Byler's disease (progressive familial intrahepatic cholestasis type 1) are unknown.

METHODS

Interactions among the apical sodium-dependent bile acid transporter, the farnesoid X receptor (FXR), and familial intrahepatic cholestasis-1 were studied in the ileum of children with progressive familial intrahepatic cholestasis type 1 and in Caco-2 cells.

RESULTS

Increased ileal apical sodium-dependent bile acid transporter messenger RNA (mRNA) expression was detected in 3 patients with progressive familial intrahepatic cholestasis type 1. Paradoxically, ileal lipid-binding protein mRNA expression was repressed, suggesting a central defect in bile acid response. Ileal FXR and short heterodimer partner mRNA levels were reduced in the same 3 patients. In Caco-2 cells, antisense-mediated knock-down of endogenous familial intrahepatic cholestasis-1 led to up-regulation of apical sodium-dependent bile acid transporter and down-regulation of FXR, ileal lipid-binding protein, and short heterodimer partner mRNA. In familial intrahepatic cholestasis-1-negative Caco-2 cells, the activity of the human apical sodium-dependent bile acid transporter promoter was enhanced, whereas the human FXR and bile salt excretory pump promoters' activities were reduced. Overexpression of short heterodimer partner but not of the FXR abrogated the effect of familial intrahepatic cholestasis-1 antisense oligonucleotides. FXR cis-element binding and FXR protein were reduced primarily in nuclear but not cytoplasmic extracts from familial intrahepatic cholestasis-1-negative Caco-2 cells.

CONCLUSIONS

Loss of familial intrahepatic cholestasis-1 leads to diminished nuclear translocation of the FXR, with the subsequent potential for pathologic alterations in intestinal and hepatic bile acid transporter expression. Marked hypercholanemia and cholestasis are predicted to develop, presumably because of both enhanced ileal uptake of bile salts via up-regulation of the apical sodium-dependent bile acid transporter and diminished canalicular secretion of bile salts secondary to down-regulation of the bile salt excretory pump.

The use of glyceryl trinitrate (GTN) in the treatment of chronic anal fissure in children

BACKGROUND

0.2 per cent topical glyceryl trinitrate (GTN) ointment heals up to two-thirds of chronic anal fissures in adults although many patients experience troublesome headaches. This double blind randomised pilot study assessed the efficacy and side effects of 0.1 and 0.05 per cent GTN ointment in treatment of chronic anal fissures in children.

MATERIAL/METHODS

15 consecutive children with chronic anal fissures were randomised to receive either 0.05 or 0.1 per cent GTN ointment applied topically twice daily for eight weeks. Clinical review was undertaken at weeks 4 and 8 and questions relating to symptoms and the incidence of headache were asked.

RESULTS

The median age of the 15 (8 male) patients was 6 years (range 3-13). There were 5 anterior and 10 posterior fissures. The median duration of symptoms was 9 (3-30) months. 13/15 (86.7%) patients were taking laxatives at the time of referral. Fissure healing was complete at 8 weeks in all seven patients who received 0.05% and in 5/8 (62.5%) patients using the 0.1% ointment (Fisher's exact test, not significant). One patient from each arm experienced headaches during the first week of the trial which resolved without treatment and did not affect compliance. There were no other side effects.

CONCLUSIONS

Topical glyceryl trinitrate ointment is effective in healing chronic anal fissures in children. Healing rates and side effect profile are comparable when either 0.05 or 0.1 per cent ointment is used.

Congenital multifocal inflammatory pseudotumor: a case report

Inflammatory pseudotumor is an uncommon benign tumor found in various sites throughout the body. The etiology is unclear with evidence to support both neoplastic and infective processes. The authors present a case with several unique features. It represents the first reported case detected antenatally. The tumor was found separately within the abdomen and thorax. The thoracic component of the tumor was managed without resection or ablative treatment but showed spontaneous regression.

Acid-secreting rectal duplication cyst with associated peptic ulcer eroding through the anal sphincters

A rectal duplication cyst with heterotopic gastric mucosa that resulted in a trans-sphincteric peptic ulcer on the opposite wall of the anus of a child is described. The management and outcome and a review of the literature is presented.

The human bile salt export pump: characterization of substrate specificity and identification of inhibitors

BACKGROUND & AIMS

The bile salt export pump (BSEP) is the major bile salt transporter in the liver canalicular membrane. Our aim was to determine the affinity of the human BSEP for bile salts and identify inhibitors.

METHODS

Human BSEP was expressed in insect cells. Adenosine triphosphatase (ATPase) assays were performed, and bile salt transport studies were undertaken.

RESULTS

The BSEP gene, ABCB11, was cloned and a recombinant baculovirus was generated. Infected insect cells expressed a 140-kilodalton protein that was absent in uninfected and in mock-infected cells. An ATPase assay showed BSEP to have a high basal ATPase activity. Transport assays were used to determine the Michaelis constant for taurocholate as 4.25 micromol/L, with a maximum velocity of 200 pmol x min(-1) x mg(-1) protein. Inhibition constant values for other bile salts were 11 micromol/L for glycocholate, 7 micromol/L for glycochenodeoxycholate, and 28 micromol/L for taurochenodeoxycholate. Cyclosporin A, rifampicin, and glibenclamide were proved to be competitive inhibitors of BSEP taurocholate transport, with inhibition constant values of 9.5 micromol/L, 31 micromol/L, and 27.5 micromol/L, respectively. Progesterone and tamoxifen did not inhibit BSEP.

CONCLUSIONS

The human BSEP is a high-affinity bile salt transporter. The relative affinities for the major bile salts differ from those seen in rodents and reflect the different bile salt pools. BSEP is competitively inhibited by therapeutic drugs. This is a potentially significant mechanism for drug-induced cholestasis.

Gastric tonometry after gastroschisis repair

Gastric tonometry and intravesical pressure measurement were performed on eight babies born with gastroschisis for 72 hours after abdominal closure. Intravesical pressure was not high. The gastric mucosal pCO2 and gastric mucosal pH remained stable and closely matched arterial values. Tonometry may be a useful technique to monitor these babies.

Application of a cardiac arrest score in patients with sudden death and ST segment elevation for triage to angiography and intervention

The aim of this study was to test a previously validated, prognostic, cardiac arrest score in patients with ST segment elevation acute myocardial infarction (AMI) who suffered a witnessed cardiac arrest and survived to emergency department admission. A consecutive series constructed retrospectively from a sudden death database (n = 22) of patients with ST segment elevation AMI resuscitated from cardiac arrest underwent angiography and angioplasty of the culprit vessel within 24 hours of presentation. A cardiac arrest score was assigned to each case by explicit criteria present on evaluation. Primary outcomes were survival to hospital discharge and the degree of neurological recovery during the hospitalization. All patients underwent successful coronary angioplasty and 77% received adjunctive intraaortic balloon counterpulsation. The overall rate of survival to discharge was 41%. For cardiac arrest scores of 0, 1, 2, and 3, respectively, the rates of neurologic recovery were 0 (0%) of 4 (95% CI 0-53%), 3 (50%) of 6 (95% CI 15-85%), 2 (67%) of 3 (95% CI 13-98%), and 9 (100%) of 9 (95% CI 72-100%), and the rates of survival to discharge were 0 (0%) of 4, (95% CI 0-53%), 2 (33%) of 6 (95% CI 6-74%), 2 (67%) of 3 (95% CI 13-98%), and 9 (100%) of 9 (95% CI 72-100%), P < 0.01 for both outcomes over ascending scores. These results suggest appropriate patients for primary angioplasty after cardiac arrest are those with ST segment elevation AMI and an emergency department cardiac arrest score of > or = 2, thus predicting a 11 (92%) of 12 (95% CI 65-100%) chance of survival to discharge.

Novel mutations responsible for autosomal recessive multisystem pseudohypoaldosteronism and sequence variants in epithelial sodium channel alpha-, beta-, and gamma-subunit genes

Multisystem pseudohypoaldosteronism (PHA), is a syndrome of unresponsiveness to aldosterone with autosomal recessive inheritance. Previously we showed that mutations in the epithelial sodium channel (ENaC) alpha-, beta-, and gamma-subunits are responsible for PHA. In this study we examined four independent probands with multisystem PHA, three of whom were born to consanguineous parents. In our search for mutations we also determined the complete coding sequences of each of the three genes encoding alpha-, beta-, and gamma-subunits in individuals representing different ethnic groups. Our analyses revealed the following homozygous mutations in three probands: 1) insertion of a T in exon 8 of the alpha ENaC gene that causes a frameshift error at Tyr(447) and leads to a premature stop codon at K459 in a Pakistani patient; 2) R508stop mutation in exon 11 of the alpha ENaC gene in an Indian patient; and 3) a splice site mutation in intron 12 of the beta ENaC gene (1669 + 1 g-->a) in a Scottish patient. The parents were heterozygous for the latter two mutations. The second mutation was previously observed in an Iranian Jewish patient. Our sequencing of the alpha-, beta-, and gamma-coding sequences revealed some sequence variants, some of which may represent single nucleotide polymorphisms. The gamma-subunit protein sequence was completely conserved in the six subjects examined. The homozygous mutations identified in the alpha and beta ENaC genes should result in reduced or abolished ENaC activity in PHA patients, explaining the disease symptoms.

The phenotypic manifestations of interstitial duplications of proximal 15q with special reference to the autistic spectrum disorders

This study investigated the phenotypic manifestations of interstitial duplications of chromosome 15 that involve the Prader-Willi/Angelman syndrome critical region (PWACR). Twenty-one affected individuals from six families were evaluated in detail, using standardized and semi-standardized measures of intelligence, psychopathology, and physical anomalies. Special attention was placed on determining the prevalence of autism spectrum disorders as well as the relationship between the parental origin of the duplication and the phenotypic effects. Assessments of the affected individuals were compared with evaluations of the unaffected relatives from the same families. Results indicated that duplications in the region were associated with variable degrees of intellectual impairments and motor coordination problems. Four of the subjects received a diagnosis of pervasive developmental disorder. Three of these cases were probands and only one met criteria for classic autism. There was very little evidence of the duplication cosegregating with autism spectrum disorder diagnosis. Paternally inherited duplications were significantly less likely to give rise to phenotypic effects. The findings indicate that duplications in the PWACR give rise to developmental delay but not necessarily autism spectrum disorders. They also suggest that phenotypic expression is dependent on the parental origin of the duplication and implicate maternally active genes in the pathogenesis of the developmental impairments. Further research will be required to clarify the range and basis of the phenotypic manifestations.

Gap junctional communication and connexin expression in cultured olfactory ensheathing cells

The olfactory ensheathing cell (OEC) is a unique glial cell able to support neurite outgrowth in the CNS throughout life. The OEC has been described as having both Schwann cell-like and astrocyte-like characteristics. The purpose of this study was to compare gap junctional communication and connexin (Cx) expression in cultured olfactory ensheathing cells with both astrocytes and Schwann cells to establish which of these two cells types they most closely resemble. We examined the Cx mRNA profile of OECs, astrocytes, and Schwann cells using primers to Cx26, Cx32, Cx37, Cx43, Cx46, and Cx50. All connexins tested except Cx50 were expressed by all three cell types when initially cultured. However, we observed differences in the levels of expression of Cx32 and Cx26 between astrocytes, Schwann cells, and OECs that became pronounced with time. All three cell types show limited and variable gap junctional communication in culture as assessed by the transfer of microinjected Lucifer yellow. OECs had limited coupling compared with Schwann cells and astrocytes, although the extent of the dye spread through OECs was more comparable to that seen with Schwann cells than astrocytes. Thus, OECs display a profile of Cx expression that more closely resembles the Cx expression of Schwann cells rather than astrocytes.

Embryonic mania

It has been previously hypothesized that hyperactivity may be one childhood form of manic-depressive disorder. The authors contend that it is unlikely that hyperactivity in general is a childhood form of manic-depressive disorder. However, included in those considered to be hyperactive may be youngsters exhibiting an embryonic form of mania. A case of a 5-year-old boy, originally thought to be hyperactive, is presented as evidence for the existence of an embryonic stage of mania. The clinical and research necessity for differentiating between hyperactivity and embryonic mania is stressed.