RESUMEN
BACKGROUND: Patients with pancreas divisum may develop pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for diagnosing pancreas divisum. Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive test reported to be highly accurate in diagnosing pancreas divisum. AIM: To evaluate the diagnostic accuracy of MRCP in detecting pancreas divisum at our institution. METHODS: We reviewed patients who underwent both ERCP and MRCP. Patients who had diagnostic endoscopic pancreatograms (ERP) after MRCP comprise the study population. Secretin was given in 113/146 patients (S-MRCP). The remaining 33/146 patients had MRCP without secretin. In 7/33 patients who underwent MRCP without secretin (21.2%), the studies were non-diagnostic and, therefore, this group was not further analyzed and the study focused on the S-MRCP group only. RESULTS: ERP identified pancreas divisum in 19/113 (16.8%) patients. S-MRCP identified 14/19 pancreas divisum and was false-positive in three cases (sensitivity 73.3%, specificity 96.8%, positive predictive value 82.4%, negative predictive value 94.8%). Of the eight patients with inaccurate S-MRCP, 5 (63%) had changes of chronic pancreatitis by ERP. This differs from the frequency of chronic pancreatitis by ERP in 24/105 (23%) patients with accurate MRCP findings. The ERCP findings of chronic pancreatitis were more frequent among incorrect S-MRCP interpretations than among correct interpretations (odds ratio [OR] 5.5 [95% confidence interval (CI) 1.3-25.3]). MRCP without secretin is non-diagnostic for pancreas divisum in a significant proportion of patients. S-MRCP had a satisfactory specificity for detecting pancreas divisum. However, the sensitivity of S-MRCP for the diagnosis of pancreas divisum was modest at 73.3%. This is low compared to previous smaller studies, which reported a sensitivity of MRCP of up to 100%.
Asunto(s)
Pancreatocolangiografía por Resonancia Magnética , Páncreas/anomalías , Páncreas/patología , Colangiopancreatografia Retrógrada Endoscópica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Páncreas/diagnóstico por imagen , Estudios Retrospectivos , Secretina , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Guide wires are commonly utilized to facilitate endoscopic procedures. However, their use may adversely influence the results of sphincter of Oddi manometry, thereby leading to erroneous diagnosis and therapy. The aim of this study was to evaluate the effect of guide wires on the basal pressure of the biliary sphincter of Oddi. METHODS: Forty-five consecutive patients with suspected sphincter of Oddi dysfunction were enrolled. Biliary sphincter of Oddi manometry was performed with and without a guide wire in the conventional retrograde fashion with a low-compliance infusion pump system, an aspirating catheter, and slow station pull-throughs. Three types of guide wires were studied: the Roadrunner (18 patients), the Glidewire (17 patients), and the standard Teflon guide wire (10 patients). The stiffness of the guide wires was tested and reported in Taber Stiffness Units (TSU; higher values represent greater stiffness). RESULTS: Biliary sphincter of Oddi manometry performed with a guide wire revealed higher basal pressure than the same measurement performed without a guide wire (52 +/- 33.4 mmHg vs. 34.4 +/- 20.5 mmHg; P = 0.001). Basal pressure changes induced by guide-wire use were highest in the Roadrunner group (32.9 +/- 33.9 mmHg), lowest in the standard Teflon group (11.6 +/- 8 mmHg; Roadrunner vs. standard Teflon: P = 0.02), and intermediate in the Glidewire group (17.1 +/- 22.1 mmHg). The use of a guide wire resulted in crossover from normal to abnormal basal pressure in 11 cases (Roadrunner, 7; Glidewire, 4) and from abnormal to normal in 2 (Roadrunner, 1; Glidewire, 1). Concordance between recordings obtained with and without guide wire was seen in 32 patients (71 %). Guide-wire stiffness was: Roadrunner: 0.74 TSU; Glidewire: 0.153 TSU; standard Teflon guide wire: 0.077 TSU. CONCLUSION: The use of guide wires frequently alters the basal biliary sphincter pressure, leading to incorrect diagnoses in approximately 40 % of cases. The basal pressure alterations depend on the stiffness of the guide wire used. Hence, the use of guide wires during sphincter of Oddi manometry is strongly discouraged.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica/métodos , Manometría/instrumentación , Disfunción del Esfínter de la Ampolla Hepatopancreática/diagnóstico , Esfínter de la Ampolla Hepatopancreática/fisiopatología , Femenino , Humanos , Masculino , Ensayo de Materiales , Docilidad , Presión , Esfínter de la Ampolla Hepatopancreática/patología , Disfunción del Esfínter de la Ampolla Hepatopancreática/fisiopatologíaRESUMEN
BACKGROUND: Chronic radiation proctopathy (CRP) is a troublesome complication of radiotherapy to the pelvis for which current treatment modalities are suboptimal. Currently, the application of formalin to the rectal mucosa (AFR) and thermal ablation with argon plasma coagulation (APC) are the most promising options. OBJECTIVE: To compare the efficacy and safety of AFR with APC for CRP. PATIENTS AND METHODS: Records of 22 patients (male to female ratio, 19:3; mean age, 74 years) who received either APC or AFR for chronic hematochezia caused by CRP, and who were evaluated and treated between May 1998 and April 2002, were reviewed. Complete evaluations were made three months after completion of each therapeutic modality. Patients were considered to be responders if there was a 10% increase in hemoglobin from baseline or complete normalization of hemoglobin (male patients, higher than 130 g/L; female patients, higher than 115 g/L) without the requirement for blood transfusion. RESULTS: The mean hemoglobin level before therapy was 107 g/L. Patients received an average of 1.78 sessions for APC and 1.81 sessions for AFR. Eleven patients (50%) were treated with APC alone, eight patients (36%) with AFR alone and three (14%) with both modalities (two with AFR followed by APC, and one with APC followed by AFR). Eleven of 14 patients (79%) in the APC group were responders, compared with three of 11 patients (27%) in the AFR group (P=0.017). In the APC group, seven of 11 responders required only a single session, while in the AFR group, only one patient responded after a single session. Adverse events (nausea, vomiting, flushing, abdominal cramps, rectal pain and fever) occurred in two patients after APC and in nine patients after AFR (P=0.001). In the APC group, the mean hemoglobin level increase was 20 g/L at three months follow-up, compared with 14 g/L in the AFR group. CONCLUSION: This retrospective study suggests that APC is more effective and safe than topical AFR to control hematochezia caused by CRP. Further studies are needed to confirm this observation.
Asunto(s)
Coagulación con Láser , Láseres de Gas/uso terapéutico , Traumatismos por Radiación/terapia , Recto/efectos de la radiación , Administración Tópica , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Femenino , Fijadores , Formaldehído/administración & dosificación , Humanos , Mucosa Intestinal/efectos de la radiación , Masculino , Traumatismos por Radiación/etiología , Radioterapia/efectos adversos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
AIM: To review the computed tomography (CT), magnetic resonance imaging (MRI) and cholangiographic findings of chemotherapy-induced sclerosing cholangitis (CISC). METHODS: Between January 1995 and December 2004, 11 patients in the endoscopic retrograde cholangiography database were identified with CISC. Twelve CT, four MRI, 69 endoscopic and nine antegrade cholangiographic studies in these patients were reviewed. Serial change in appearance and response to endoscopic treatment were recorded. RESULTS: CISC showed segmental irregular biliary dilatation with strictures of proximal extrahepatic bile ducts. The distal 5cm of common bile duct was not affected in any patient. CT and MRI findings included altered vascular perfusion of one or more liver segments, liver metastases or peritoneal carcinomatosis. Biliary strictures needed repeated stenting in 10 patients (mean: every 4.7 months). Cirrhosis (n=1) or confluent fibrosis (n=0) were uncommon findings. CONCLUSION: CISC shares similar cholangiographic appearances to primary sclerosing cholangitis (PSC). Unlike PSC, biliary disease primarily involved ducts at the hepatic porta rather than intrahepatic ducts. Multiphasic contrast-enhanced CT or MRI may show evidence of perfusion abnormalities, cavitary liver lesions, or metastatic disease.
Asunto(s)
Antineoplásicos/efectos adversos , Colangitis Esclerosante/inducido químicamente , Adulto , Anciano , Colangitis Esclerosante/diagnóstico , Femenino , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND AND STUDY AIMS: The development of anastomotic strictures is one of the most common complications of orthotopic liver transplantation (OLT) with choledochocholedochostomy anastomosis. Endoscopic therapy with balloon dilation and/or stent placement is an effective therapy. The aim of this study was to assess the recurrence rate of anastomotic strictures and the features that predict recurrence after previously successful endoscopic therapy. PATIENTS AND METHODS: We searched the endoscopic retrograde cholangiopancreatography (ERCP) database for all patients who had had an OLT who were undergoing ERCP. The study cohort consisted of post-OLT patients who had a recurrence of anastomotic stricture after initial resolution following a course of endoscopic therapy. RESULTS: A total of 916 OLT operations were performed during the study period from June 1994 to November 2004. Out of this group, 143 patients (15.6 %) were diagnosed with anastomotic stricture and underwent a total of 423 ERCPs for endoscopic treatment. Twelve patients who are still undergoing endoscopic therapy were excluded from the analysis. The technical success rate was 96.6 %, and the endoscopic therapy was successful in 82 % of patients; 18 % had a recurrence of cholestasis and ERCP revealed a recurrence of the anastomotic stricture that required intervention. The mean time of follow-up after stent removal was 28 months (range 1 - 114 months). The study did not reveal any clinical or endoscopic parameters that could predict recurrence, though the presence of a biliary leak at initial ERCP and a longer time to initial presentation were factors that showed a trend toward an increased likelihood of recurrence. CONCLUSIONS: Biliary strictures remain a common complication after OLT, and in nearly one in five patients these strictures recur after initially successful endoscopic therapy. There were no clinical or endoscopic parameters identified in this study that predicted recurrence. Further study is needed to determine what type of endoscopic therapy would minimize the risk of stricture recurrence.