Diagnosis and treatment of caecal volvulus

Caecal volvulus is an infrequently encountered clinical condition and an uncommon cause of intestinal obstruction. Patients with this condition may present with highly variable clinical presentations ranging from intermittent, self limiting abdominal pain to acute abdominal pain associated with intestinal strangulation and sepsis. Lack of familiarity with this condition is a factor contributing to diagnostic and treatment delays. The objective of this review is to promote clinicians' awareness of this disease through patient case illustration, discussion of disease pathogenesis, clinical features, and management strategies.

Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy

OBJECTIVE

To assess the utility of triage guidelines for patients with cholelithiasis and suspected choledocholithiasis, incorporating selective use of magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiopancreatography (ERCP) before laparoscopic cholecystectomy (LC).

SUMMARY BACKGROUND DATA

ERCP is the most frequently used modality for the diagnosis and resolution of choledocholithiasis before LC. MRC has recently emerged as an accurate, noninvasive modality for the detection of choledocholithiasis. However, useful strategies for implementing this diagnostic modality for patient evaluation before LC have not been investigated.

METHODS

During a 16-month period, the authors prospectively evaluated all patients before LC using triage guidelines incorporating patient information obtained from clinical evaluation, serum chemistry analysis, and abdominal ultrasonography. Patients were then assigned to one of four groups based on the level of suspicion for choledocholithiasis (group I, extremely high; group 2, high; group 3, moderate; group 4, low). Group 1 patients underwent ERCP and clearance of common bile duct stones; group 2 patients underwent MRC; group 3 patients underwent LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography.

RESULTS

Choledocholithiasis was detected in 43 of 440 patients (9.8%). The occurrence of choledocholithiasis among patients in the four groups were 92.6% (25/27), 32.4% (12/37), 3.8% (2/52), and 0.9% (3/324) for groups 1, 2, 3, and 4, respectively (P <.001). MRC was used for 8.4% (37/440) of patients. Patient triage resulted in the identification of common bile duct stones during preoperative ERCP in 92.3% (36/39) of the patients. Unsuspected common bile duct stones occurred in six patients (1.4%).

CONCLUSIONS

The probability of choledocholithiasis can be accurately assessed based on information obtained during the initial noninvasive evaluation. Stratification of risks for choledocholithiasis facilitates patient management with the most appropriate diagnostic studies and interventions, thereby improving patient care and resource utilization.

Inflammatory pseudotumor presenting as a cystic tumor of the pancreas

Inflammatory pseudotumor (IPT) of the pancreas occurs rarely. Eighteen cases have been described in the English literature. In all previous patients IPT of the pancreas presented as solid pancreatic mass. We are reporting a case of IPT presenting as a cystic mass of the pancreas, which has not been described previously. A review of IPT of the pancreas and a discussion regarding the management of pancreatic cystic neoplasm is provided.

The efficacy of magnetic resonance cholangiography for the evaluation of patients with suspected choledocholithiasis before laparoscopic cholecystectomy

BACKGROUND

Endoscopic retrograde cholangiography is the most commonly utilized tool for the identification of common bile duct stones (CBDS) before laparoscopic cholecystectomy, whereas the role of magnetic resonance cholangiography (MRC) for patient evaluation before laparoscopic cholecystectomy is currently undefined.

METHODS

We prospectively evaluated the efficacy of MRC for the identification of CBDS among patients with high risk for choledocholithiasis. Patient selection was based on clinical, sonographic, and laboratory criteria. Standard cholangiograms were obtained when possible for verification of MRC results.

RESULTS

Ninety-nine patients underwent evaluation with preoperative MRC. CBDS was visualized in 30% of patients. MRC sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 85%, 90%, 77%, 94%, and 89%, respectively.

CONCLUSIONS

MRC is useful for the evaluation of patients with suspected choledocholithiasis. Advantages of MRC include its noninvasive nature, ease of application, and accuracy in identifying and estimating the size of CBDS. Application of MRC in this setting reduces the need for diagnostic endoscopic retrograde cholangiography. Future investigations should be directed at the development of cost-effective utilization strategies for MRC application.