Endoscopic management of bile duct stones: residual bile duct stones after surgery, cholangitis, and "difficult stones"

Endoscopic treatment has become, according to the latest recommendations, the standard treatment for common bile duct stones (CBDS), although in certain situations, surgical clearance of the common duct at the time of laparoscopic cholecystectomy is still considered a possible alternative. The purpose of this article is not to compare endoscopic with surgical treatment of CBDS, but to describe the various techniques of endoscopic treatment, detailing their preferential indications and the various treatment options that must sometimes be considered when faced with "difficult calculi" of the CBD. The different techniques of lithotripsy and the role of biliary drainage with plastic or metallic stents will be detailed as well as papillary balloon dilatation and particularly the technique of sphincterotomy with macrodilatation of the sphincter of Oddi (SMSO), a recently described approach that has changed the strategy for endoscopic management of CBDS. Finally, the overall strategy for endoscopic management of CBDS, with description of different techniques, will be exposed.

Colonisation bactérienne chronique de l’intestin grêle révélée par un érythème pellagroïde et une panniculite

INTRODUCTION

Pellagra is an exceptional disorder in France. The classical description of pellagra associates a photoinduced rash with neurological impairment and intestinal dysfunction. Without adapted treatment, the progression is fatal.

CASE REPORT

A 62 year-old women developed a photoinduced rash, composed of circular and erythematous elements with pustular edges. She also had panniculitis, peripheral neuropathy, depressive mood and diarrhea. Her medical past was marked by epilepsy treated with sodium valproate and hydantoin. Biological exams revealed lowered plasma levels of vitamins PP, B1, B6 and zinc, secondary to intestinal impairment induced by bacteria proliferating in the small intestine. The rash resolved with vitamin PP and zinc supplementation. The bacterial colonisation was improved by long-term, sequential antibiotics.

DISCUSSION

We report a rare clinical form of pellagroid rash. The rash was induced by chronic malabsorption resulting from excessive bacterial proliferation in the diverticules of the small intestine. The antiepileptic treatment could have facilitated vitamin PP et zinc deficiency. Panniculitis was related to the bacterial proliferation. We discuss in this paper the relationship between some vitamin deficiencies, their clinical manifestations and the direct role of intestinal bacterial proliferation in the cutaneous manifestations.

[Morbidity and mortality of acute pancreatitis. Prospective study in a French university hospital]

OBJECTIVE

According to certain learned societies, acute pancreatitis mortality should not exceed 10%. The aim of our work was to review the etiology, severity and mortality of acute pancreatitis in a prospective series of patients admitted to a regional university hospital in France, using standardised collection of data assessing the medico-surgical habits in the management of acute pancreatitis.

METHODS

From February to September 1999, 86 patients (54 men and 32 women with a mean age of 58.5 years) were admitted for 88 episodes of acute pancreatitis. Data was collected from all the patients on admission and permitted measurement of the severity and prognosis scores and the study of the etiology, complications and management of the latter and the mortality with acute pancreatitis.

RESULTS

Ranson's score was a mean of 2.4. Balthazar's score was superior or equal to D in 45% of cases. The respective prevalence of lithiasis, alcoholism, tumors, others or undetermined was of 41%, 37.5%, 7%, 5.5% and 9%. Acute pancreatitis was severe (multi organ failure, pseudo-cyst, systemic or necrotic infection and occlusive syndrome) in 32% of cases. Complications were: infection (22%), pseudo-cyst (14%), pleural effusion (12.5%) and occlusive syndrome (3.5%). Fever of more than 38.5 degrees C was noted in more than half of the patients. The median duration of hospitalisation was of 11 days (range: 1-86 days). Global hospital mortality was of 13.6% (12/88), and of 43% (12/28) in cases of severe acute pancreatitis. Six deaths occurred within the first 8 days of acute pancreatitis, and 6 after 8 days. Seven deaths (59%) were due to multi organ failure, 4 (33%) to infectious causes and one to another cause.

CONCLUSION

The standardized collection of clinical and progressive data used in this study permitted assessment of the medico-surgical habits in a regional university hospital.

Serum amylase and lipase activities in normal pregnancy: a prospective case-control study

OBJECTIVE

The diagnosis of acute pancreatitis during pregnancy is usually based on the association of upper abdominal pain, nausea or vomiting, and elevated serum amylase or lipase activities. The changes in these enzymatic activities have not been clearly established during normal pregnancy. The aim of this study was therefore to evaluate serum amylase and lipase activities in healthy pregnant women.

METHODS

Serum amylase and lipase activities were measured in 103 pregnant women (first trimester, n = 34; second trimester, n = 36; third trimester, n = 33) and in 103 nonpregnant women matched for age and not receiving oral contraception.

RESULTS

Serum amylase activity was similar in pregnant women and nonpregnant women during all trimesters of pregnancy. Serum lipase activity was significantly lower during the first trimester of pregnancy compared to nonpregnant women (48.6+/-27.6 vs 59.2+/-29.3 IU/L, p < 0.05) and compared to the third trimester (48.6+/-27.6 vs 76.3+/-35.8 IU/L, p < 0.001). Serum lipase activity was not statistically different between pregnant and nonpregnant women during the second and third trimesters.

CONCLUSION

An increase in serum amylase and lipase activities during pregnancy should be taken into account, as in nonpregnant women.

[Small intestine bacterial overgrowth: six case reports and literature review]

INTRODUCTION

Small intestinal bacterial overgrowth syndrome (SIBOS) has various clinical and biological presentations. Six observations are described in this review which is aimed at reporting recent data on SIBOS and proposing diagnosis and therapeutic attitudes.

CURRENT KNOWLEDGE AND KEY POINTS

Chronic diarrhea, malabsorption syndrome and exsudative enteropathy are the main criteria of diagnosis. Breath hydrogen testing is commonly performed to confirm diagnosis, with a 78% sensitivity and a 89% specificity. The aim of therapy is reparation of malabsorption consequences, reduction of intestinal bacterial overgrowth, and surgical correction of intestinal stasis. In the absence of consensus, norfloxacin or amoxicillin-clavulinic acid (administered for a mean of 7 to 15 days) seem the more appropriate antibiotics. When possible, surgery represents the primary treatment of SIBOS recurrences.

FUTURE PROSPECTS AND PROJECTS

Diagnosis of small intestinal bacterial overgrowth syndrome must be evoked on the basis of either surgical or medical context, i.e., the existence of chronic diarrhea, malabsorption syndrome (complete or not), and exsudative enteropathy. This review reports essential factors for diagnosis and treatment.

[Yellow nail syndrome associated with intestinal lymphangiectasia]

The yellow nail syndrome, a combination of yellow discoloured nails, lymphedema and pleural effusions, is a rare clinical condition. We report a case of the yellow nail syndrome associated with intestinal lymphangiectasia revealed by chylous ascites and protein-losing gastroenteropathy. This association reported in only three cases in the literature leads us to discuss the relations between yellow nail syndrome, primitive intestinal lymphangiectasia and primary lymphatic disorders.

Differentiation of human embryonic stem cells into embryoid bodies compromising the three embryonic germ layers

BACKGROUND

Embryonic stem (ES) cells are lines of cells that are isolated from blastocysts. The murine ES cells were demonstrated to be true pluripotent cells as they differentiate into all embryonic lineages. Yet, in vitro differentiation of rhesus ES cells was somewhat inconsistent and disorganized. The recent isolation of human ES cells calls for exploring their pluripotential nature.

MATERIALS AND METHODS

Human ES cells were grown in suspension to induce their differentiation into embryoid bodies (EBs). The differentiation status of the human ES cells and EBs was analyzed by following the expression pattern of several lineage-specific molecular markers using reverse transcription polymerase chain reaction (RT-PCR) and in situ hybridization.

RESULTS

Here we report the induction in vitro of cystic embryoid bodies from human ES cells. Our findings demonstrate induction of expression of cell-specific genes during differentiation of the human ES cells into EBs. In the human EBs, we could show a characteristic regional expression of embryonic markers specific to different cellular lineages, namely, zeta-globin (mesoderm), neurofilament 68Kd (ectoderm), and alpha-fetoprotein (endoderm). Moreover, we present a synchronously pulsing embryoid body that expresses the myocardium marker alpha-cardiac actin. In addition, dissociating the embryoid bodies and plating the cells as monolayers results in multiple morphologies, among them cells with neuronal appearance that express neurofilament 68Kd chain.

CONCLUSION

Human ES cells can reproducibly differentiate in vitro into EBs comprising the three embryonic germ layers. The ability to induce formation of human embryoid bodies that contain cells of neuronal, hematopoietic and cardiac origins will be useful in studying early human embryonic development as well as in transplantation medicine.

[Low-grade gastric MALT lymphoma and helicobacter heilmannii (Gastrospirillum hominis]

We report the fourth case of low-grade gastric MALT lymphoma associated to Helicobacter heilmannii. This spiral organism may be present in the gastric mucosa of animals where it is non pathogenic while, in humans, its presence is always associated with chronic gastritis. In this case, Helicobacter heilmannii was observed in the absence of Helicobacter pylori. Regression of endoscopic and histological lesions after Helicobacter heilmannii eradication suggests its role in gastric lymphoma. This observation underlines the need for searching for Helicobacter heilmannii by careful histological examination, in the absence of Helicobacter pylori, and the importance of its eradication in the treatment of gastric lymphoma.