Charles Ruchti

High coincidence of Mirizzi syndrome and gallbladder carcinoma

BACKGROUND Mirizzi syndrome is a rare complication of long-standing cholelithiasis. It is defined as obstructive jaundice caused by external compression of the common hepatic duct by an impacted stone in the gallbladder neck. Gallstone disease and cholelithiasis-associated chronic biliary inflammation may play a causative role in the pathogenesis of gallbladder carcinoma. The purpose of this study was to investigate the coincidence of gallbladder carcinoma associated with Mirizzi syndrome. Furthermore, the diagnostic value of elevated CA 19-9 levels as indicator for a coincidental gallbladder carcinoma in this syndrome was studied. METHODS Patient demographics, clinical findings, laboratory data, results of diagnostic studies, pathologic reports, and intraoperative findings of 1579 patients undergoing cholecystectomy were obtained from patient records and were retrospectively studied. Only patients with proven Mirizzi syndrome (i.e., extrinsic mechanical compression of the common hepatic duct by impacted gallstones, associated chronic cholecystitis, and a history of jaundice) were included in this study. RESULTS Eighteen cases of Mirizzi syndrome (1.0%) out of 1759 cholecystectomies performed between January 1986 and March 1995 were identified. The seven male patients and 11 female patients had an average age of 74.8 years (range, 32 to 87 years). In five of these patients (27.8%) coincidental cases of gallbladder carcinoma were detected. The incidence of unsuspected malignancies in long-standing gallstone disease was 36 (2%) of 1759 and was statistically significantly different (p < 0.001) from the incidence in patients with Mirizzi syndrome (27.8%, 5 of 18). No significant difference was noted in age, gender, duration of jaundice, and type of lesions between these two groups. Tumor-associated antigen CA 19-9 level was elevated in 12 patients with Mirizzi syndrome, but it was significantly higher (p < 0.0001) in all five patients with coincidental gallbladder neoplasm and peaked at 1000 units/ml. All patients diagnosed with gallbladder carcinoma died within 18 months after operation. CONCLUSIONS There is high association of gallbladder cancer in Mirizzi syndrome. Elevated CA 19-9 levels in this syndrome are indicative of a coincidental gallbladder malignancy. Because of this high coincidence of Mirizzi syndrome and gallbladder cancer we recommend an intraoperative frozen section of the gallbladder in all patients presenting with Mirizzi syndrome.

Gastrospirillum hominis in Asymptomatic, Healthy Individuals

Gastrospirillum hominis is a spiral-shaped bacterium found in the stomach. It has been implicated as a possible cause of chronic gastritis. We report two cases ofG. hominis colonization observed in a series of 175 healthy, asymptomatic volunteers investigated forHelicobacter pylori. None of the volunteers has symptoms or a history of gastrointestinal disease. Both carriers ofG. hominis had histological signs of chronic, active antral gastritis. Multiple tests forH. pylori were negative. The prevalence of this spiral bacterium in healthy, asymptomatic individuals may be as low as in symptomatic persons.

Helicobacter pylori and gastric erosions. Results of a prevalence study in asymptomatic volunteers.

Background/Aims: Helicobacter pylori is considered to be the primary cause of most forms of gastritis, but its role as a causative agent in gastric erosions is unclear. The aim of this study was to estimate the prevalence of gastric erosions and H. pylori infection in asymptomatic volunteers. Methods: 175 asymptomatic subjects underwent upper gastrointestinal endoscopy. Antral biopsies were taken for bacterial cultures, histology and quick urease (CLO) test. A 13C-urea breath test was performed after endoscopy. NSAID intake, alcohol consumption and smoking habits were also recorded in each subject. Results: 33 (19%) of 175 asymptomatic volunteers had macroscopic lesions on upper gastrointestinal endoscopy, 7 were H. pylori positive, 26 were H. pylori negative. Gastric erosions occurred in 8% (14 subjects) of all volunteers. 10 subjects were H. pylori negative and 4 H. pylori positive. In 11 volunteers, gastric erosions were restricted to the prepyloric antrum. Only 1 of 14 subjects had a history of NSAID intake and 6 subjects were alcohol abstainers. Conclusion: We conclude that gastric erosions occur in a considerable amount of asymptomatic volunteers. They are predominantly localized in the prepyloric antrum and are most likely not associated with H. pylori infection, NSAID intake, smoking or alcohol consumption.

Mesenteric Inflammatory Veno-Occlusive Disease: A Rare Cause of Intestinal Ischemia

Background: Mesenteric inflammatory veno-occlusive disease (MIVOD) is a rare cause of intestinal ischemia of unknown etiology. Histologically, MIVOD is characterized by extended thrombophlebitis and fibrous organized thrombosis of multiple veins. The arteries are by definition not involved. Management includes surgery in all cases described. Recurrence has not been described until now. Methods: We describe the case of a 64-year-old woman operated with the suspicion of intestinal ischemia. Clinical and histopathological characteristics are reported. Results: The patient underwent a right hemicolectomy and segmental resection of the terminal ileum 15 months later for a recurrence. The histological examination of the resected specimen confirmed the diagnosis of MIVOD and a recurrence thereof. Conclusion: MIVOD is a rare cause of colonic ischemia. Recurrence of the disease, which is described here for the first time, is unusual after surgical resection.

Regional differences in renewal rates of fibroblasts in young adult female mice

SummaryYoung adult female mice were given a total of 90 intraperitoneal injections each of (methyl-3H)thymidine (3HTdR) at intervals of 8 h over 30 days to establish renewal rates of fibroblasts in various locations. Radioautographs prepared from punch biopsy material of the ears, taken repeatedly during the labeling procedure, revealed an approximately linear increase of labeling indices of dermal fibroblasts with time. Labeling indices of fibroblasts at the end of repetitive injections of 3HTdR differed depending on the site and/or type of connective tissues examined. Low values were obtained for fibroblasts in the leptomeninx (3.9%), the tracheal wall (4.4%), the achilles tendon (5.8%) and the dermis of the ear (6.5%), while higher values were registered for fibroblasts located in the lower half of the abdominal dermis (12.3%), peritendinous sheaths (12.6%), the interstitial connective tissue of the thigh muscles (12.9%), the submucosa of the colon (23%), the fibrous capsule of the adrenals (25.7%), and the upper half of the abdominal dermis (26%). These regional differences, with the exception of the skin and possibly of the tracheal wall, did not correlate with local temperature. Possible additional factors influencing fibroblast renewal rates may include the type of connective tissue, the degree of vascularization, mechanical stress and hormonal action. Estimated turnover times, based on the assumptions of a DNA synthesis time of 6 h or more and a linear increase of labeling indices as a function of time of repetitive labeling, range from about 90 to more than 700 days. The higher values approximate the median life span of the mouse strain used.

CASE REPORT: Juvenile Idiopathic Fibrosing Pancreatitis

Chronic pancreatitis is a rare differential diagnosis of obstructive jaundice and/or recurrent abdominal pain in childhood and adolescence. The hereditary calcifying and the noncalcifying obstructive form are the two major forms of juvenile chronic pancreatitis. Other causes include cystic fibrosis, hyperparathyroidism, hyperlipoproteinemia and ascariasis. Even less common is the so called idiopathic or fibrosing pancreatitis. Since the first description by Comfort in 1946 only 41 further cases of juvenile idiopathic fibrosing pancreatitis have been published. An association with gene mutations (PRSS1, SPINK1, CTFR-5T genotype) is suspected. We report the cases of a 17-year-old male patient who presented with painless obstructive jaundice and a 16-year-old female patient who presented with abdominal pain and obstructive jaundice. Both patients underwent surgical treatment with duodenum-preserving pancreatic head resection. The relevant literature with special regard to modern pancreatic surgery is reviewed to give an overview about this rare but surgically treatable pediatric condition, which merits the attention of pediatricians and gastroenterologists in cases of children and adolescents suffering from unexplained abdominal pain.

Inhibition of iodine organification and regulation of follicular size in rat thyroid tissue in vitro

The factors mediating the accumulation of thyroglobulin are of great importance to the understanding of the pathogenesis of human and experimentally induced colloid goiters. To elucidate further the underlying cellular mechanism, thyroid fragments from newborn rats were incorporated into semisolid alginate beads and were cultured as three-dimensional organoids for up to 21 d. In five parallel cultures, the medium contained either no supplements (group A), Nal (group B), thyroid-stimulating hormone (TSH) (group C), Nal plus TSH in the same concentrations as B and C (group D), or Nal and TSH (as in group D) plus methimazole (MMI, group E). The thyroid organoids maintained morphological intergrity, functional activity, and ability to proliferate in vitro. Addition of iodine to the cultures significantly increased mean (±SEM) follicular diameters from 19.5±0.7 μm in controls to 33.9±2.2 μm (p<0.0001) when Nal was added alone (group B), and 30.4±1.7 μm (p<0.0001) when combined with TSH (group D). The effect of Nal on follicular size was abolished by MMI (group E, follicular diameter 23.5±1.3 μm). The results presented support the recent finding, using a rat colloid goiter model, that not only TSH but also iodine organification or its inhibition are important factors in modulating follicular morphology.