Fatal acute acalculous cholecystitis as an early complication after radiation therapy

Acute acalculous cholecystitis (AAC) is a life-threatening condition whose incidence is steadily increasing, although it is still very much lower than that of the corresponding calculus form. The severity of the disease is due to the rapid course towards gallbladder necrosis and biliary peritonitis. Traditionally, it has been thought that AAC is associated with recent trauma, overeating or major surgical procedures. We describe a patient who presented acute cholecystitis, two days after completion of radiation therapy for metastatic lymphadenopathy along the hepatoduodenal ligament and distal common bile duct. He underwent exploratory laparotomy but he died from uncontrolled sepsis three days later. Histological study of the resected gallbladder showed findings of acute acalculous cholecystitis.

Endoscopic Mucosal Resection of Lateral Spreading Tumors of the Colon Using a Novel Solution

Lateral spreading tumors (LSTs) of the colon are lesions over 10 mm in diameter that are low in height and grow superficially. They are increasingly being diagnosed in Western cohorts. The aim of this study was to investigate the safety and efficacy of dextrose 50% solution in the endoscopic mucosal resection (EMR) of LSTs. The study population consisted of 21 patients with LSTs of the colorectum. The mean size of the LSTs was 23.52+/-13.60 mm. Dextrose 50% solution was injected, via a variceal needle, into the submucosa to lift up the LST sufficiently from the proper muscle layer. Subsequently, a snare was positioned around the lesion and then closed while being pressed against the mucosa, with suction being applied to draw the lesion into the snare. Blended current was used for resection. If necessary, a piecemeal technique was used to achieve complete resection. Immediate and delayed complications were recorded. After the EMR, patients were followed up at 3, 6, and 12 months or later, using total colonoscopy. Endoscopic resection was completed in all LSTs. Of the 21 LSTs, 15 (71.4%) were resected en bloc and 6 (28.6%) piecemeal. The mean amount of injected dextrose 50% solution was 14.86+/-9.13 mL. One patient (4.78%) had immediate bleeding after EMR, which was stopped endoscopically. Histologic examination of resected LSTs showed adenoma with high-grade dysplasia 9 (42.9%), adenoma with low-grade dysplasia 10 (47.6%), and invasive carcinoma 2 (9.5%). Twenty patients were followed up for 37.9+/-24.03 months. Local recurrent disease was detected in 4 patients (20%), all within 6 months of the index EMR. These recurrent lesions were completely resected endoscopically. The contribution of submucosal injection of dextrose 50% is significant for a safe and efficient EMR of LSTs of the colorectum.

Topical 0.5% nifedipine vs. lateral internal sphincterotomy for the treatment of chronic anal fissure: long-term follow-up

BACKGROUND

The aim of this study was to compare the efficacy of the local application of 0.5% nifedipine ointment vs. lateral internal sphincterotomy in the healing of chronic anal fissure.

PATIENTS AND METHODS

Sixty-four patients with symptomatic chronic anal fissures were randomly assigned to 0.5% nifedipine ointment (n=32) every 8 h for 8 weeks or lateral internal sphincterotomy (n=32). Both groups received stool softeners and fiber supplements and were assessed at 2, 4, 6, and 8 weeks. Long-term outcomes were determined after a median follow-up of 19 months (nifedipine group) and 20.5 months (lateral internal sphincterotomy group).

RESULTS

Complete healing at 8 weeks was achieved in 30 out of 31 patients (96.7%) in the nifedipine group and 32 out of 32 patients (100%) in the lateral internal sphincterotomy group (p=0.49). The overall healing rates at the end of follow-up were 28 out of 30 (93%) vs. 32 out of 32 (100%) in the nifedipine and sphincterotomy groups respectively (p=0.48). Two of the 30 patients in the nifedipine group relapsed whereas none in the sphincterotomy group did. Sixteen patients (50%) developed side effects in the nifedipine group, compared with six patients (18.7%) in the sphincterotomy group.

CONCLUSIONS

Topical application of 0.5% nifedipine ointment represents a new, promising, easily handled, effective alternative to lateral internal sphincterotomy.

Safety and long-term follow-up of endoscopic snare excision of ampullary adenomas

BACKGROUND

Adenomas of the duodenal papilla are rare. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection techniques, transduodenal local excision, and pancreaticoduodenectomy. The aim of this retrospective study was to evaluate the safety and outcome of endoscopic snare resection of papillary adenomas in a Greek cohort of patients.

METHODS

Fourteen patients (six women and eight men; age range, 42-76 years) were referred for endoscopic management of ampullary adenomas. A questionnaire was completed for each patient, which included preoperative and postoperative data points. Presenting symptoms were jaundice (n = 4), cholangitis (n = 1), and pain (n = 2). Seven patients were asymptomatic. If there was no common bile and main pancreatic duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy onto normal duodenal tissue was performed. The adenomas were resected via a diathermy snare, along with the major papilla, after elevation of the lesion by epinephrine plus dextrose 50% (1:10,000) solution. At the discretion of the endoscopist, a biliary or pancreatic stent was inserted as a prophylactic procedure immediately after excision.

RESULTS

Histopathologically, resected tissue included 11 adenomas and three adenomas with focal malignancy, referred for pancreaticoduodenectomy. Immediate complications were moderate bleeding (n = 1) and mild pancreatitis (n = 1). No procedure-related death occurred. Follow-up was available for 11 patients (mean, 28.36 months; range, 6-72). Pancreatic and biliary stents were placed in four and nine patients, respectively. Follow-up endoscopy revealed recurrent/residual adenomatous tissue in two patients (18%), which was resected endoscopically.

CONCLUSION

Endoscopic snare resection of adenomas of the major duodenal papilla is a safe, well-tolerated alternative to surgical therapy. In expert hands, complications are mild and may be avoided by pre-resection biductal sphincterotomy, stent placement, and elevation of the lesion by epinephrine plus dextrose 50% solution injection.

Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips

Perforation is one of the most serious complications of endoscopic sphincterotomy (ES) necessitating immediate surgical intervention. We present a case of successful management of such a complication with endoclipping. A 85-year-old woman developed duodenal perforation after ES. The perforation was identified early and its closure was achieved using three metallic clips in a single session. There was no procedure-related morbidity or complications and our patient was discharged from hospital 10 d later. Endoclipping of duodenal perforation induced by ES is a safe, effective and alternative to surgery treatment.

The administration of cisapride as an adjuvant to PEG-electrolyte solution for colonic cleansing: a double-blind randomized study

BACKGROUND/AIMS

Traditional bowel preparation before colonoscopy involves lavage with approximately 4L of polyethylene glycol (PEG)-electrolyte solution. Only a few studies have been published evaluating the use of cisapride in routine bowel preparation.

METHODOLOGY

We conducted a blinded, placebo-controlled trial with the prokinetic agent, cisapride, in addition to standard PEG-electrolyte lavage. Of 115 patients undergoing colonoscopy, 58 were randomized (double-blind) to PEG plus cisapride (10 mg per os thrice per day three days before the procedure and one 10-mg dose on the morning of the procedure) and 57 to PEG plus a placebo of identical appearance. The adequacy of the preparation was scored on a four-point grading scale for each anatomic-segment and for the overall impression. A questionnaire was also used to assess each patient's symptoms during lavage.

RESULTS

The difference in the overall score between the two groups was not significant (p=0.21). The quality of bowel preparation was significantly better in transverse (p=0.001), ascending (p=0.0053), and cecum (p=0.0001) in the cisapride group than in the placebo group. The differences in symptoms scores between the two groups were not significant in nausea, abdominal cramps and bloating but there was improvement in symptom score of vomiting in cisapride group (p=0.0422).

CONCLUSIONS

The administration of cisapride to patients undergoing colonic lavage may be an effective adjuvant to PEG-electrolyte solution particularly with respect to increase patient acceptability.

Endoscopic sphincterotomy in patients with "acalculus" cholangitis associated with juxtapapillary diverticula

BACKGROUND/AIMS

The aim of this study was to investigate patients who underwent endoscopic sphincterotomy for "acalculus" cholangitis associated with juxtapapillary diverticula.

METHODOLOGY

In a retrospective study we analyzed 87 patients who underwent endoscopic sphincterotomy for cholangitis; the cholangitis considered "acalculus", when outlining the extra- and intrahepatic bile ducts, we could not observe any intraluminal defect or stricture, and during the clearing of the bile ducts with the balloon, after endoscopic sphincterotomy, there was no evidence of stones, fragments of stones or sludge. Patients who had undergone previous endoscopic sphincterotomy, or who had additional pancreatobiliary diseases were excluded from this study. There were 11 patients with "acalculus" cholangitis associated with juxtapapillary diverticula, and sufficient clinical data available for this study.

RESULTS

Nine patients presented pain, fever, and jaundice. In two patients diagnosis was established via the test of abnormal liver biochemistry. Seven patients had positive blood cultures and three of them developed confusion and hypotension. Endoscopic sphincterotomy succeeded in all cases; no evidence of stones, fragments of stones or sludge was recorded during the clearing of bile ducts, after endoscopic sphincterotomy, with the balloon. Five patients presented mild post-endoscopic sphincterotomy complications successfully treated. In the follow-up period, from 4 months to 7 years after endoscopic sphincterotomy, none of the patients developed symptoms of cholangitis.

CONCLUSIONS

We recommend endoscopic sphincterotomy in patients with "acalculus" cholangitis associated with juxtapapillary diverticula, despite the absence of obvious obstruction, and the possible morbidity which is inherent with an invasive procedure like endoscopic sphincterotomy.

Dieulafoy-like lesion of the colon presenting with massive lower gastrointestinal bleeding

The Dieulafoys lesion is a rare cause of severe gastrointestinal hemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. We describe an elderly patient who presented with severe lower gastrointestinal bleeding caused by a colonic Dieulafoy-like lesion. This is the third report of colonic Dieulafoys lesion treated successfully with endoscopic hemoclipping. We review the pathophysiology, clinical presentation, diagnosis, and treatment of this rare disease.

Endoscopic snare resection of an intrapapillary pedunculated villous adenoma presenting as acute recurrent pancreatitis

Tumors of the papillary region are an unusual and heterogeneous group of neoplasms that arise from the major papilla, the ampulla of Vater, and the peripapillary duodenum. Benign adenomas of the papilla of Vater are an increasingly recognized condition in those with familial adenomatous polyposis syndromes as well as sporadic cases. Papillary adenoma is a recognized but rare cause of acute pancreatitis. We describe a patient who presented with acute recurrent pancreatitis that was attributed to an intrapapillary pedunculated villous adenoma. Following diagnosis by endoscopic needle knife sphincterotomy and endoscopic retrograde cholangiopancreatography, endoscopic snare resection of the adenoma resulted in symptomatic improvement.

Pyogenic cholangitis after inadvertent submucosal contrast injection in the papilla of Vater in a patient with cholestatic hepatitis

Common bile duct stones and tumors constitute the leading cause of acute biliary tract obstruction and cholangitis. Septic complications after diagnostic endoscopic retrograde cholangiopancreatography (ERCP) are very unusual in unobstructed bile ducts. There are only three reported cases of patients without evidence of biliary tract disease who developed cholangitis and liver abscesses due to Pseudomonas aeruginosa. Biliary endoscopists believe that the inadvertent submucosal injection of contrast into the papilla of Vater is an innocent accident that has no serious consequences other than increasing the percentage of unsuccessful catheterizations of the common bile duct. Herein we describe a patient with drug-induced cholestatic hepatitis who developed pyogenic cholangitis after the inadvertent injection of submucosal contrast in the papilla of Vater.

The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones

BACKGROUND

Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting.

METHODS

Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients.

RESULTS

In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced.

CONCLUSIONS

These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.

Endoscopic sphincterotomy for cholangitis after recent coronary artery bypass graft surgery

It is particularly attractive to perform endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy for cholangitis due to common bile duct stone because of the increased morbidity and mortality of the alternative therapy of choledochal exploration. The safety of therapeutic ERCP after recent myocardial injury is unknown since there are only five previously reported cases. Three patients underwent therapeutic ERCP after recent coronary artery bypass graft surgery for indication of recent cholangitis due to choledochal stones. Initially, the cholangitis was managed medically in all patients. Endoscopic sphincterotomy (ES) was performed 11, 17, and 14 days after coronary artery bypass graft surgery. The calculi were successfully extracted by sweeping the choledochus with a balloon-tipped catheter or basket in all cases. During ERCP the vital signs remained stable; no cardiac arrhythmias, hemorrhage, or pulmonary complications occurred. Our study demonstrates that therapeutic ERCP is not absolutely contraindicated after recent myocardial injury and suggests that ES is preferable to surgery for cholangitis due to common bile duct stones.

Double Dieulafoy-like lesion in the stomach

Dieulafoy's lesion is an uncommon cause of major gastrointestinal bleeding and may be difficult to recognize. It consists of an arteriole that protrudes through a tiny mucosal defect usually within 6 cm of the gastroesophageal junction on the lesser curve of the stomach. Despite widespread awareness of this entity, it remains a diagnostic challenge for gastroenterologists because of its small size and hidden location. Emergency endoscopy is the most effective method of diagnosing the disease. We report a patient, with double Dieulafoy-like lesion, who was successfully treated endoscopically using hemostatic clip application. The characteristics of the Dieulafoy's lesion, its current diagnosis, and its treatment are discussed.

Hemolysis caused by G-6PD deficiency after a difficult and prolonged therapeutic endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP), together with its substantial therapeutic capabilities, carries a higher potential for complications than other endoscopic procedures. Common major complications specific to pancreaticobiliary instrumentation include pancreatitis, post-sphincterotomy hemorrhage, perforation, and cholangitis with or without systemic sepsis. Two patients underwent therapeutic ERCP for recurrent episodes of abdominal pain and elevation of hepatobiliary enzymes. Endoscopic sphincterotomy was difficult and prolonged. The calculi were successfully extracted by sweeping the choledochus with a balloon-tipped catheter or basket in both cases. The patients experienced postprocedure diffuse abdominal pain unassociated with nausea or vomiting. Laboratory data showed normal serum amylase and lipase 2, 6, and 18 h after the end of procedure, a fall in hematocrit level, and an increase of indirect bilirubin and lactic dehydrogenase. The abdominal pain subsided in 4 to 6 h. The hematocrit level remained stable during the next 3 days, and the patients were very well when discharged. Examination of glucose-6-phosphate dehydrogenase (G-6PD) enzyme levels in red cells 20 days later showed complete enzyme deficiency. This report highlights the importance of examining G-6PD deficiency in patients with post-ERCP abdominal pain, normal serum amylase and lipase, and laboratory findings of hemolysis.

Black esophagus induced by severe vomiting in a healthy young man

Black esophagus is an uncommon entity that has been described only a few times previously. It is defined as a dark pigmentation of the esophagus associated with histologic mucosal necrosis. Most cases have no known etiology, although ischemia, nasogastric tube trauma, infection, gastric outlet obstruction, gastric volvulus, and hypersensitivity to antibiotics have all been suggested as possible causes. Herein we report the case of a young, healthy, athletic man who developed black esophagus due to severe vomiting after alcohol overindulgence and summarize the other published cases to date.

Needle-knife sphincterotomy

Choledochocele, now classified as choledochal cyst type III, is a rare anomaly of the terminal biliary tree causing abdominal pain, pancreatitis, and obstructive cholestasis. Traditionally, the therapy for this malformation has been surgery. Recently, endoscopic therapy has been used alternatively for the treatment of choledochocele mainly in adults. We report two patients with recurrent episodes of acute pancreatitis found to be caused by a large choledochocele; both patients were treated by needle-knife sphincterotomy without complications. They remained asymptomatic at 1 and 2 years' follow-up, respectively. Despite the fact that the risk of bleeding seems to be higher using needle-knife sphincterotomy, when the Choledochocele is large, our experience suggests that needle-knife sphincterotomy can be performed accurately and safely. Further studies are necessary to confirm the safety and effectiveness of needle-knife sphincterotomy in large choledochocles.

Acute recurrent pancreatitis associated with anomalous pancreaticobiliary ductal union and choledochal cyst of mixed type I plus II

Anomalous pancreatobiliary ductal union (APBDU) has a variety of presentations. We report the case of a 72-year-old woman who presented with recurrent episodes of acute pancreatitis that were found to be caused by the presence of an APBDU associated with an unusual choledochal cyst of mixed type I plus II. She underwent endoscopic sphincterotomy and has remained asymptomatic to the present time, 2 years after sphincterotomy. A discussion of the possible etiologies of choledochal cyst and pancreatitis due to APBDU is presented.

Pseudomonas aeruginosa liver abscesses after diagnostic endoscopic retrograde cholangiography in two patients with sphincter of Oddi dysfunction type 2

Patients with sphincter of Oddi dysfunction have a significantly increased rate of pancreatitis after manometry or sphincterotomy, but septic complications after diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in patients with sphincter of Oddi dysfunction type 2 have not been reported. We describe two patients with sphincter of Oddi dysfunction type 2 in whom Pseudomonas aeruginosa serotype 10 septicemia and multiple small hepatic abscesses developed, all within 48 h after they underwent diagnostic ERCP. The sepsis and hepatic abscesses resolved after successful intravenous antibiotic administration. Despite scrupulous examination of the duodenoscope washing machine and the bottle of water, the bacteria responsible for the sepsis could not be isolated. It is possible that despite disinfection, a nondetectable colony of P. aeruginosa remained in a part of duodenoscope and proliferated to reach a potentially hazardous level the following day. This report highlights the importance administering antibiotic prophylaxis to patients with sphincter Oddi dysfunction type 2 who undergo ERCP, despite the functional nature of the disease.

Biliary stricture due to neuroma after an innocent blunt abdominal trauma

A traumatic neuroma of the biliary tract is rarely associated with biliary obstruction. However, when it arises in the common bile duct (CBD) and is associated with obstructive jaundice, it is difficult to distinguish it from bile duct cancer. We describe a patient who developed obstructive jaundice and itching, due to CBD stricture, 8 years after innocent blunt abdominal trauma. The stricture was resected and hepatico-jejunal anastomosis was performed. Histological examination revealed a traumatic neuroma and a fibrous scar around the common bile duct. Symptoms disappeared following surgical removal of the lesion. Blunt abdominal injury may cause the late onset of a fibrous scar and traumatic neuroma in the common bile duct. To our knowledge, a traumatic neuroma of the biliary tract after blunt abdominal trauma has not been reported previously. We review the clinical picture of this relatively rare problem, along with its diagnosis, pathogenesis and treatment.

Successful treatment of duodenal bulb obstruction caused by a gallstone (Bouveret's syndrome) after endoscopic mechanical lithotripsy

Because of acute symptoms in the upper abdomen, upper gastrointestinal endoscopy was performed in a 68-year-old man. A large perforated gallstone was embedded in the duodenum, causing complete obstruction of the duodenal bulb. The stone was crushed successfully by endoscopic mechanical lithotripsy. The patient was referred for surgery, and was discharged after a successful and uneventful cholecystectomy.

Colopathy associated with the systemic use of nonsteroidal antiinflammatory medications. An underestimated entity

BACKGROUND/AIMS

Adverse effects of NSAIDs (nonsteroidal antiinflammatory drugs) on the upper gastrointestinal tract and small intestine are well described. Evidence is also accumulating that implicate NSAIDs in inducing and exacerbating damage in the distal gastrointestinal tract. In this article we describe eight cases of colonic inflammation associated with nonsteroidal antiinflammatory drug administration; our aim is to stress the importance of an underestimated entity by clinicians.

METHODOLOGY

Over a five-year period at two clinics, eight cases of NSAID-colopathy have been diagnosed. Crohn's disease, ulcerative and infections colitis have been excluded from this analysis. In all these subjects a careful drug history has been taken in a prospective manner and colonic inflammation appeared to be directly related to NSAID administration. There was a time interval (mean: 20 months) between initiation of treatment with NSAID and presentation with diarrhea, rectal hemorrhage and tenesmus.

RESULTS

A correct diagnosis of colopathy associated with NSAIDs administration was made on careful drug history, pathological findings, stool cultures and biochemical changes which were insignificant, in contrast to the protracted troublesome symptoms. Resolution of symptoms was observed on discontinuation of NSAID medication.

CONCLUSIONS

Our report is further evidence that NSAIDs administration is associated with significant mucosal injury in the distal gastrointestinal tract, despite is underestimated by most physicians.