Albano Rosa

Screening for pancreatic exocrine insufficiency in patients with diabetes mellitus

OBJECTIVES:Fecal elastase 1 (E1) is a relatively sensitive and specific indirect test of pancreatic exocrine function. Despite the high functional reserve of the pancreas, it is recognized that a significant proportion of diabetic patients may also have a deficit of the exocrine function. The aim of this study was to screen patients with diabetes mellitus (DM) for pancreatic exocrine insufficiency.METHODS:A total of 80 patients were enrolled in this prospective study, including 42 patients with DM and 38 nondiabetic controls. Exclusion criteria were as follows: age >75 yr; alcohol intake >40 g/day; intake of orlistat or acarbose; and history of diarrhea, pancreatitis, GI surgery, immunodeficiency, or cancer. All patients underwent the same study protocol, which included clinical evaluation, determination of fecal E1, plain x-rays of the abdomen, and abdominal ultrasound. An immunoenzymatic method (ScheBoTech, Wettenburg, Germany) was used for E1 determination. Diagnosis of pancreatic insufficiency was established for a fecal E1 <200 μg/g.RESULTS:The DM and control groups were comparable regarding age (62 ± 10 yr vs 56 ± 10 yr), sex (18 men and 24 women vs 15 men and 23 women), and proportion of patients with excess weight (50% vs 42%). Patients had DM diagnosed for 11.5 ± 8 yr, with structural changes of the pancreas detected on ultrasound in three cases and calcifications in one case. There was no relationship between E1 determination <200 μg/g and the duration or the type of therapy for DM. Fifteen patients (36%) in the DM group had a fecal E1 <200 μg/g, compared with two patients (5%) in the control group (p < 0.05). In the DM group (n = 42), 11 patients with excess weight presented a fecal E1 <200 μg/g, whereas four patients with a BMI <25 presented this result (p < 0.05).CONCLUSIONS:Pancreatic exocrine insufficiency occurs more frequently in diabetic patients than in controls. Diabetic individuals with excess weight (BMI >25) may be at increased risk for underlying exocrine pancreatic insufficiency.

Fosinopril-induced prolonged cholestatic jaundice and pruritus: first case report.

We report a case of fosinopril-induced prolonged cholestatic jaundice and pruritus in a 61-year-old man, with no previous hepatobiliary disease, who presented with asthenia, jaundice and itching 3 weeks after starting fosinopril therapy. Other drugs taken by the patient were not considered probable causes. The diagnostic evaluation showed no biliary obstruction and other possible causes of intra-hepatic cholestasis were excluded. Liver biopsy showed cholestasis without bile duct damage. The disease ran a severe course during the 2 months of hospitalization, with prolonged itching for 6 months, eventually controlled with oral naltrexone. Jaundice subsided after 4 months, with anicteric cholestasis persisting for more than 18 months. Similar occurrences have been reported with other inhibitors of angiotensin-converting enzyme (mostly captopril), but this is the first case of an important adverse reaction to fosinopril.

Ticlopidine-induced prolonged cholestasis: a case report.

We report a case of ticlopidine-induced prolonged cholestasis in a 60-year-old man with no previous hepatobiliary disease who presented with sudden right upper abdominal pain, jaundice and pruritus three months after starting ticlopidine therapy. Other drugs taken by the patient were not considered probable causes. The diagnostic evaluation showed no biliary obstruction and other possible causes of intra-hepatic cholestasis were excluded. The liver biopsy showed a cholestatic hepatitis with bile duct damage. The disease ran a severe and protracted course, but symptoms and jaundice eventually subsided five months after drug withdrawal. More than a year later, relevant abnormalities of liver function tests consistent with anicteric cholestasis still persist, fulfilling criteria for a minor form of drug-induced prolonged cholestasis. This syndrome has been reported infrequently in relation to several drugs, mainly chlorpromazine, and only once with ticlopidine.

Mesenteric arteriovenous fistula causing portal hypertension and bleeding duodenal varices

We report a case of portal hypertension associated with a non-traumatic arteriovenous fistula, presenting with bleeding duodenal varices. The patient was admitted for melaena. Emergency endoscopy showed oesophageal varices with no signs of recent bleeding and with no blood in the upper gastrointestinal tract. Arteriography of the coeliac axis and superior mesenteric artery failed to detect any bleeding source. Endoscopy was repeated because of persistent bleeding and revealed active bleeding from varices in the distal duodenum. The patient underwent surgery and a large paraduodenal varicose vein associated with an arteriovenous fistula was found. Resection of the paramural varix and surgical occlusion of the arteriovenous fistula were effective in the control of bleeding. Liver biopsy revealed mild portal fibrosis without cirrhosis. Three years after surgery the patient still has oesophageal varices but has not had recurrent bleeding. There was regression of intraduodenal varices.

Team approach to ERCP-directed single-brush cytology for the diagnosis of malignancy

OBJECTIVE To evaluate the clinical usefulness of single-brush cytology performed at ERCP as initial method for detecting pancreatobiliary malignancy, ensuring a very close relationship between endoscopists, cytotechnicians, and cytopathologists. STUDY DESIGN All 125 cytodiagnoses considered in this study correspond to the first brushing for each patient, collected by one of the three members of a fixed team of endoscopists in the presence of the same cytotechnician. Smears were fixed immediately with Merckofix spray, stained with Papanicolau, and analyzed by the same cytopathologist in a laboratory exclusively devoted to gastrointestinal cytopathology located at the endoscopy unit. RESULTS Of 125 cytological diagnoses 94 were considered benign, 4 suspicious, and 27 malignant. These findings were compared to the final diagnosis of 45 malignant and 80 benign lesions obtained either by surgical pathology or after at least one year of clinical follow-up. The comparison yielded 30 true positives, 78 true negatives, 1 false positive and 16 false negative results, which corresponds to a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 65.2, 98.7, 96.8, 83, and 86.4%, respectively. CONCLUSION Results seem to confirm the usefulness of an effective team approach to ERCP-directed brush cytology for the diagnosis of pancreatobiliary malignancy. However, sensitivity continues to be rather low.

Desgarro esofágico espontáneo extenso con hemorragia digestiva alta tratado con la aplicación de un endoclip

A 61-years-old male presented with emesis after some retching episodes. He had liver cirrhosis but no previous bleeding. An upper endoscopy revealed an extensive 10 cm tear involving the mucosa and submucosa layers of the distal esophagus sparing a 2 cm long segment proximal to the Z-line (Fig. 1). The laceration presented a slowly oozing haemorrhage that was stopped with the injection of 6 cc of epinephrine 1:10,000 and application of 17 endoclips to close the laceration. Recurrent bleeding 8 days later was controlled with further application of 4 endoclips. No further haemorrhagic recurrence occurred and an endoscopy procedure was repeated at week 6 (Fig. 2) and week 24 when no lesion was seen. Spontaneous extensive esophageal tear with upper digestive haemorrhage treated by endoclip application

Acute recurrent pancreatitis due to an intraductal papillary mucinous tumor of the pancreas.

Intraductal papillary mucinous neoplasms of the pancreas (IPMN) are characterized by an adenomatous proliferation of pancreatic duct epithelium involving the main pancreatic duct, the branch ducts alone or a combination of both (1,2). IPMN often presents with acute pancreatitis of mild to moderate severity. It has been reported that approximately one-fourth of patients with IPMN experience symptoms including epigastric discomfort and/or pain and backache (3,4).

4474 Prognostics factors of death in ischemic colitis.

BACKGROUND & AIMS: Ischemic colitis (IC) is considered a disease of elderly patients who have associated diseases. The aim of this study was to evaluate the mortality prognostic factors in patients with IC. PATIENTS AND METHODS: Analysis of 66 consecutive patients (30 men and 36 women) with this disease. We evaluated clinical, analytic, endoscopic, histologic and evolutionary data. Odds Ratio (OR) and the χ 2 test were used. RESULTS: The patients age ranged from 49 to 94 years (mean : 73 years). Mean hospitalization was 15±12 days. Patients presented mainly with hematochezia (97 %) and abdominal pain (74 %). Co-morbility were present in 56 of 66 patients (85 %). Fourteen of 66 patients (22 %) were found to have more than two segments affected. The majority of lesions occured in the sigmoid colon (89 % cases). The severity endoscopic features ( Ann. Gastroenterol. Hepatol., 1990, 26 : 181-183 ) was grade I (29 %), grade II (63 %) and grade III (8 %). Ten of 66 patients (15 %) presented colonic strictures. Five of 66 patients (8 %) required surgery. Seven patients (11 %) died. The death was significantly associated with LDH>600U/l (OR=26,2; IC=2,9-240), >2 segments of colon affected (OR=37,5; IC=3,8-353,9) and subocclusion (OR=23,2; IC=1,8-302,7). Normal LDH was associated with favourable evolution (OR=0,04; IC=0-0,35). CONCLUSIONS: Increased LDH (>600U/l), extension of colitis and subocclusion were significant prognostics factors of death.