Fh Al-Kawas

Complications of gallstone disease: mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus

Gallstone is a common disease with a 10% prevalence in the United States and Western Europe. However, it is only symptomatic in 20–30% of patients, with biliary pain “colic” being the most common symptom. Complications of asymptomatic gallstone disease are generally rare, with an incidence of <1%/yr. The most common complications of gallstone disease are acute cholecystitis, acute pancreatitis, ascending cholangitis, and gangrenous gallbladder. Less frequent complications include Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Mirizzi syndrome and cholecystocholedochal fistula are two manifestations of the same process that starts with impaction of a gallstone in the gallbladder neck that results in obstruction of the bile duct, causing jaundice. The gallstone may erode into the bile duct, causing cholecystocholedochal fistula. Gallstone ileus refers to small bowel obstruction resulting from the impaction of one or more gallstones after they have migrated through a cholecystoenteric fistula. An accurate diagnosis is essential to the management and prevention of further complications. A variety of imaging and endoscopic modalities are used to make the diagnosis once the condition is suspected clinically. Treatment should be tailored to each individual patient. Management choices include ERCP, lithotripsy (endoscopic or extracorporeal), and surgery. Prognosis is frequently related to early recognition, management of any comorbid conditions, and careful selection of treatment modalities.

The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated

BACKGROUNDnPeptic ulcer disease is considered the cause of upper-GI bleeding in 50% of cases. A recent decline in the proportion of cases of upper-GI bleeding because of a peptic ulcer was noted by us. The objectives of this study were to evaluate the frequency of peptic ulcer in patients with upper-GI bleeding and the proportion of bleeding peptic ulcers with a non-bleeding visible vessel.nnnMETHODSnPatients with upper-GI bleeding seen from December 1999 until April 2001 at a tertiary, university-affiliated medical center were studied prospectively. The Clinical Outcome Research Initiative (CORI) database was used to correlate the single institution data with nationwide data. Endoscopic data in the CORI database for patients who had endoscopy for upper-GI bleeding between December 1999 and July 2001 were retrieved and analyzed.nnnRESULTSnA total of 126 patients were included in the prospective study. The endoscopic findings were: peptic ulcer in 31.8%: 95% confidence interval (CI) [23.7%, 40.6%] of patients; a non-bleeding visible vessel was present in 10%: 95% CI[2.8%, 23.7%] of these peptic ulcers. From the nationwide CORI database, data for 7822 patients with upper-GI bleeding were obtained. The endoscopic findings were: peptic ulcer in 20.6%:95% CI[19.7%, 21.5%] of patients with upper-GI bleeding; a non-bleeding visible vessel was present in 7.3%: 95% CI[6.1%, 8.6%] of the ulcers.nnnCONCLUSIONSnThe frequency of peptic ulcer in patients with upper-GI bleeding and the proportion of bleeding ulcers with a non-bleeding visible vessel are less than previously reported.

Biliary sludge and obstruction: Another sign of a delayed hemolytic transfusion reaction

An 81-year-old physician was transfused with 2 units of red blood cells (RBCs) for an acute gastrointestinal hemorrhage and anemia. At that time, anti-E (only) was identified in his plasma, which was attributed to transfusions during cardiac surgery 21 years previously. Both units of transfused RBCs were Eand crossmatch compatible. On Day 18 after the transfusion, he developed fever, severe diarrhea, and dark urine. After an increased aspartate aminotransferase (AST), bilirubinemia (fractionation not performed), and bilirubinuria (suggestive of direct hyperbilirubinemia) were observed, his primary care physician suspected choledocholithiasis (stones within the common bile duct [CBD]). He ordered an abdominal ultrasound, which showed a dilated CBD. On Day 23, endoscopic ultrasound revealed sludge in the gallbladder and distal CBD (see figure, left), and endoscopic retrograde cholangiography confirmed the presence of sludge in the distal CBD. A plastic stent was placed to facilitate biliary drainage (see figure, right). Retrospective review of a computerized tomogram of the abdomen performed 3 months previously for an unrelated illness did not reveal sludge in the gallbladder or CBD. The patient’s hematocrit (Hct) was 29.6% 3 days before the endoscopy. A routine postendoscopy Hct was unexpectedly low, 20.7%. The patient denied any symptoms to suggest recurrent gastrointestinal bleed. He was admitted to Georgetown University Hospital for blood transfusion. Upon admission (Day 19), the

Transfusion medicine illustrated. Biliary sludge and obstruction: another sign of a delayed hemolytic transfusion reaction.

An 81-year-old physician was transfused with 2 units of red blood cells (RBCs) for an acute gastrointestinal hemorrhage and anemia. At that time, anti-E (only) was identified in his plasma, which was attributed to transfusions during cardiac surgery 21 years previously. Both units of transfused RBCs were Eand crossmatch compatible. On Day 18 after the transfusion, he developed fever, severe diarrhea, and dark urine. After an increased aspartate aminotransferase (AST), bilirubinemia (fractionation not performed), and bilirubinuria (suggestive of direct hyperbilirubinemia) were observed, his primary care physician suspected choledocholithiasis (stones within the common bile duct [CBD]). He ordered an abdominal ultrasound, which showed a dilated CBD. On Day 23, endoscopic ultrasound revealed sludge in the gallbladder and distal CBD (see figure, left), and endoscopic retrograde cholangiography confirmed the presence of sludge in the distal CBD. A plastic stent was placed to facilitate biliary drainage (see figure, right). Retrospective review of a computerized tomogram of the abdomen performed 3 months previously for an unrelated illness did not reveal sludge in the gallbladder or CBD. The patient’s hematocrit (Hct) was 29.6% 3 days before the endoscopy. A routine postendoscopy Hct was unexpectedly low, 20.7%. The patient denied any symptoms to suggest recurrent gastrointestinal bleed. He was admitted to Georgetown University Hospital for blood transfusion. Upon admission (Day 19), the

Re: Anderson et al. —women, BMI, and Colonoscopy

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