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BACKGROUND AND STUDY AIMS: The diagnosis of anorectal dynamic disorders and perineal insufficiency has been mainly based up to now on the use of defecography. Here, we performed a prospective blinded study to evaluate the accuracy of a new procedure, dynamic anorectal endosonography (DAE), by comparing it with defecography. PATIENTS AND METHODS: A total of 43 women (mean age 53), presenting with outlet obstruction, were prospectively enrolled in our study. The DAE was performed with a 7.5-Mhz linear probe (Toshiba, Tokyo, Japan) with basal and straining recordings. None of the DAE or defecography operators was informed about the results of the respective other investigation. RESULTS: Defecography showed a descending perineum in 29 patients (68%), a rectocele in 25 patients (58%), and a rectal intussusception in eight patients (18%). The rate of concordance between the diagnosis of descending urinary bladder at DAE and descending perineum at defecography was 35/43 (80%), and that between the descending puborectal muscle at DAE and descending perineum at defecography was 40/43 (93 %). The rates of concordance between DAE and defecography for the diagnosis of rectocele and rectal intussusception were 27/43 patients (57%) and 34/43 patients (80%), respectively. In the last 15 patients, the DAE technique was adapted in order to improve the accuracy for diagnosing rectocele by filling the rectum with water. This improved sensitivity from 36 to 86% and accuracy from 57 to 87%. CONCLUSIONS: DAE is a new imaging approach to anorectal dynamic disorders, providing a highly reliable means of diagnosing perineal insufficiency as well as rectocele. DAE should be substituted for previous methods since it makes it possible at the same time to assess the anal sphincters and to avoid pelvic irradiation.

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OBJECTIVE: Several cases of pancreatitis have been described during the course of Crohn's disease (CD) or ulcerative colitis (UC), but many of them were related to either biliary lithiasis or drug intake. We tried to evaluate the clinical and morphological features of so-called idiopathic pancreatitis associated with inflammatory bowel disease and to define their pathological characteristics. METHODS: Chronic idiopathic pancreatitis was diagnosed on the basis of abnormal pancreatograms suggestive of chronic pancreatitis associated with or without impaired exocrine pancreatic function, or pathological examination in patients undergoing pancreatic resection. We found 6 patients presenting with features of chronic idiopathic pancreatitis and UC and 2 patients with CD seen between 1981 and 1996 in three hospital centers of the south of France. A review of the literature has identified 6 cases of pancreatitis associated with UC and 14 cases of pancreatitis associated with CD based on the above criteria. RESULTS: Hyperamylasemia was not a sensitive test since it was present in 44% and 64% of patients with UC or CD. In UC, pancreatitis was a prior manifestation in 58% of patients. In contrast, the pancreatitis appeared after the onset of CD in 56% of the cases. In patients with UC, pancreatitis were associated with severe disease revealed by pancolitis (42%) and subsequent surgery. Bile duct involvement was more frequent in patients with UC than with CD (58% vs 12%) mostly in the absence of sclerosing cholangitis (16% vs 6%). Weight loss and pancreatic duct stenosis were also more frequent in UC than in CD (41% vs 12% and 50% vs 23%, respectively). Pathological specimens were analyzed in 5 patients and demonstrated the presence of inter- and intralobular fibrosis with marked acinar regression in 3 and the presence of granulomas in 2 patients, both with CD. CONCLUSIONS: Pancreatitis is a rare extraintestinal manifestation of inflammatory bowel disease. Chronic pancreatitis associated with UC differs from that observed in CD by the presence of more frequent bile duct involvement, weight loss, and pancreatic duct stenosis, possibly giving a pseudotumor pattern.

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BACKGROUND: The existence of endosonographic abnormalities of the oesophagus in achalasia is discussed. The place of endoscopic ultrasonography (EUS) needs to be clarified. PATIENTS: Thirty five untreated patients suffering from achalasia and 28 controls without oesophageal disease were prospectively enrolled since 1993. Pseudoachalasia was diagnosed in two patients. METHODS: EUS measurements were performed at two opposite sites at the level of the cardia, and 5 cm and 10 cm proximally, avoiding compression by the water filled balloon. RESULTS: The oesophageal wall and the fourth hypoechoic layer were significantly thicker at the level of the cardia and 5 cm above, with mean differences between patients and controls of 0.37/0.42 mm and 0.16/0.23 mm respectively. No statistically significant correlation could be demonstrated between the thickness of the oesophageal wall or of the fourth hypoechoic layer and weight loss, or the average pressure of the lower oesophageal sphincter. However, a significant inverse relationship was demonstrated between the duration of symptoms and the thickness of the fourth hypoechoic layer. The thickness of the fourth hypoechoic layer was also increased in patients who required only one pneumatic dilatation (P < 0.01). CONCLUSION: The thickness of the oesophageal wall and of the fourth hypoechoic layer appeared to be significantly increased in achalasia patients. However, the slight increase of the mean size (< 0.5 mm) of the muscularis propria suggests that EUS is not helpful in the diagnosis of achalasia. The physiopathological basis of advanced achalasia has to be reconsidered as we demonstrated an inverse relationship between the duration of symptoms and the thickness of the muscularis propria.

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BACKGROUND: Trimebutine is an opiate modulator of the gastrointestinal motility that interacts with enkephalinergic receptors. AIM: To evaluate the effects of trimebutine (50 mg intravenous injection) on the motility of the sphincter of Oddi (SO) as assessed by endoscopic manometry. METHODS: Endoscopic manometry was performed on 15 cholecystectomized patients who presented with symptoms suggestive of SO dysfunction. Prior to the endoscopic manometry, endoscopic ultrasonography was performed in order to rule out the possible presence of a bile duct stone. RESULTS: Injecting trimebutine resulted in a significant increase in the SO antegrade phasic contraction rate (P = 0.02). Trimebutine decreased the basal pressure of the SO (32.5 vs. 27.5 mmHg), but the difference is not statistically significant (P = 0.11). The effects of trimebutine differed depending on the basal SO motility anomalies involved, but the period of latency was similar (mean 89 s: range 30-240 s). The basal anomalies were an increased basal SO pressure of > 40 mmHg in three patients, a tachyoddia (frequency of phasic contractions (PC) > 10/min) in six patients, prolonged PC (> 10 s) in two patients and an absence of phasic contraction in one patient. The basal pressure of the SO decreased in the three patients presenting with SO hyperpressure, but returned to a normal value in one case. The frequency of the PC decreased to normal in three out of the six patients with tachyoddia. The duration of the PC returned to normal in the two patients with prolonged PC whereas their frequencies increased. Prolonged PC developed in the patient without any detectable phasic contraction. CONCLUSIONS: Trimebutine modulates SO motility in various ways depending on the basal SO motility anomaly observed after cholecystectomy. This regulatory effect suggests the existence of encephalinergic control of SO motility.

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Pseudo-tumoral hyperplasia of the Brünner glands is an exceptional dysembryoplastic or hyperplastic lesion which develops in the submucosa of the supra papillary proximal duodenum. We report a case of Brünner adenoma which led to duodenal obstruction. In 50% of the cases, the adenoma was asymptomatic but non-specific signs may lead to barium studies. CT scan of the abdomen or esogastroduodenal endoscopy which rarely provides formal histological proof. Major complications (hemorrhage, duodenal obstruction) and lack of formal diagnosis often leads to surgery, ideally with tumor resection after duodenotomy. Other prodecures (simple observation, endoscopic polypectomy, duodenopancreatectomy, biliary or digestive bypass without tumorectomy) may be entertained depending on the functional status, the volume of the tumor, presence of complications and overall general status.

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OBJECTIVE, PATIENTS AND METHODS: The objective of this study was to evaluate the results of palliative bipolar electrocoagulation probe (BICAP) treatment in 26 patients with non surgical, obstructive esophageal cancer. The mean tumor length was 7.2 cm. The strictures were located as follows: 3 in the cervical esophagus, 8 in the thoracic esophagus, 13 in the distal third of the esophagus and 2 involved both the cervical and thoracic esophagus. Most lesions were circumferential (73% versus 27% non circumferential) and exophytic (78% versus 22% sub mucosal). Coagulation was carried out under direct endoscopic control in the forward direction. The success of treatment was evaluated on the basis of the degree of reopening achieved (easy passage of an endoscope 12 mm in diameter) and good functional results (improvement of dysphagia, scored from 0 to 4 using a standard grading scale, for more than 15 days). RESULTS: Twenty-six patients underwent a total of 45 BICAP treatments (31 initial sessions, 14 repeated sessions). Reopening was achieved in 92% of cases and good functional results were obtained in 85% (mean dysphagia score: 3.2 before treatment versus 1.1 after treatment). The improvement of dysphagia resulted in a significant improvement of general performance status and stabilization or weight improvement in 21 patients. The mean number of sessions necessary for good initial results was 1.2 +/- 0.4. After the initial treatment by BICAP, radiotherapy or radiochemotherapy were respectively associated in 4 and 10 patients. The median duration of improvement was significantly longer in patients who underwent radiochemotherapy as compared with patients treated by BICAP alone (22 weeks versus 4 weeks). During the follow-up, 9 patients required several BICAP treatments and at the end of their disease, 12 patients underwent other palliative procedures. Major complications occurred in 4 cases (2 esotracheal fistulas, 1 hemorrhage, and 1 aspiration pneumonia) and mortality related to the procedure was 8%. CONCLUSIONS: Palliative BICAP treatment of obstructing esophageal and cardial cancer provide quick relief of dysphagia but repeated treatment sessions are necessary to maintain initial improvement. The procedure requires a short hospitalization stay and can be easily accomplished in all cases regardless of the tumor features.

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We report a case of metastasis to the uterine corpus revealing a primary gastric adenocarcinoma. A 26-year-old woman suffered from weight loss, vaginal bleeding, abdominal pain. An endometrial curettage showed apparently metastatic adenocarcinoma. The primary site of the tumour was gastric. The upper gastrointestinal endoscopy revealed an ulcus and aspect of linitis plastica in the fundus. Biopsies showed diffuse type adenocarcinoma. Because of extensive disease, laparotomy was not performed and exclusive palliative chemotherapy was started. The patient died 10 months after the diagnosis. Metastasis from primary gastric cancer to the female genital tract are rare and are usually observed in young premenopausal women with diffuse type gastric adenocarcinoma. This case report underlines the interest, for those patients of careful gynaecologic examination at the initial staging and after treatment.

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Benign cysts of the spleen (excepting parasites) are rare. Less than 10% of the cases involve epidermoid cysts, as the two cases reported here. These lesions are often asymptomatic and can lead unspecific clinical manifestations. The diagnosis is based on echography and abdominal computed tomography. Generally, imagery can eliminate a hydatic cyst of the spleen but cannot differentiate between different types of non-parasite cysts. Major complications including rupture and intracystic haemorrhage, malignant transformation and the impossibility of obtaining a preoperative histological diagnosis make surgery the only possible treatment. A conservative approach with partial splenectomy is the usual option, but total splenectomy may be required. The question of whether surgery is always necessary for small asymptomatic cysts of the spleen in under debate. Certain authors suggest that only regular echographic monitoring is necessary.

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