Ann Marie Joyce

Update on biliary endoscopy.

Purpose of review Since the introduction of endoscopic retrograde cholangiopancreatography, there have been great improvements in the technique, equipment, and clinical utility of biliary endoscopy. In many cases, therapeutic endoscopic retrograde cholangiopancreatography can take the place of invasive surgery, including common bile duct exploration, thereby decreasing the patients morbidity and recuperation time. Even with advances, such as stent placement for biliary strictures in a patient after liver transplantation, there is still room for improvement. Recent findings Research over the past year has been focused on areas including improved imaging and tissue sampling of the biliary tree through endoscopic ultrasound techniques, better identification of patients at risk for pancreatitis after endoscopic retrograde cholangiopancreatography, and refinements in photodynamic therapy for the treatment of cholangiocarcinoma. International research has continued to emphasize biliary sphincterotomy compared with balloon dilation for the management of choledocholithiasis. Further developments in other fields, such as living related liver transplantation, provide challenges for the biliary endoscopist. Summary This review focuses on some of the work being performed in the field of biliary endoscopy. The key studies were chosen to highlight some of the areas currently being investigated as well as to indicate certain fields that need further development.

Recurrent Clostridium difficile colitis. Tackling a tenacious nosocomial infection.

PREVIEW Antibiotic-associated colitis caused by the bacterium Clostridium difficile is one of the most common nosocomial infections. In this article, Drs Joyce and Burns explore the conditions that allow C difficile colitis to occur and the reasons that it is so difficult to eradicate. They suggest treatment methods to kill vegetative spores, restore normal colonic flora, and avoid the development of bacterial resistance.

Conservative management of small bowel perforation in Ehlers-Danlos syndrome type IV.

Ehlers-Danlos syndrome (EDS) is a group of inherited connective tissue disorders caused by collagen synthesis defects. EDS type IV, or vascular EDS, is caused by loss-of-function mutations in the type III pro-collagen gene (COL3A1). Common complications of EDS type IV include gastrointestinal bleeding and bowel perforations, posing diagnostic and therapeutic dilemmas for both surgeons and gastroenterologists. Here, we describe a complicated case of EDS type IV in a 35-year-old caucasian female who presented with overt gastrointestinal bleeding. The patient had a prior history of spontaneous colonic perforation, and an uncomplicated upper endoscopy was performed. A careful ileoscopy was terminated early due to tachycardia and severe abdominal pain, and a subsequent computed tomography scan confirmed the diagnosis of ileal perforation. The patient was managed conservatively, and demonstrated daily improvement. At the time of hospital discharge, no further episodes of gastrointestinal blood loss had occurred. This case highlights the benefit of conservative management for EDS patients with gastrointestinal hemorrhage. It is recommended that surgical treatment should be reserved for patients who fail conservative treatment or in cases of hemodynamic instability. Finally, this case demonstrates the necessity for a higher threshold of operative or endoscopic interventions in EDS type IV patients.