Jan Stovicek

What is the role of endoscopic retrograde cholangiopancreatography in assessing traumatic rupture of the pancreatic in children

Abstract Background and study aims: Trauma is one of the most common causes of morbidity and mortality in the pediatric population. The diagnosis of pancreatic injury is based on clinical presentation, laboratory and imaging findings, and endoscopic methods. CT scanning is considered the gold standard for diagnosing pancreatic trauma in children. Patients and methods: This retrospective study evaluates data from 25 pediatric patients admitted to the University Hospital Motol, Prague, with blunt pancreatic trauma between January 1999 and June 2013. Results: The exact grade of injury was determined by CT scans in 11 patients (47.8%). All 25 children underwent endoscopic retrograde cholangiopancreatography (ERCP). Distal pancreatic duct injury (grade III) was found in 13 patients (52%). Proximal pancreatic duct injury (grade IV) was found in four patients (16 %). Major contusion without duct injury (grade IIB) was found in six patients (24%). One patient experienced duodeno-gastric abruption not diagnosed on the CT scan. The diagnosis was made endoscopically during ERCP. Grade IIB pancreatic injury was found in this patient. One patient (4%) with pancreatic pseudocyst had a major contusion of pancreas without duct injury (grade IIA). Four patients (16%) with grade IIB, III and IV pancreatic injury were treated exclusively and nonoperatively with a pancreatic stent insertion and somatostatine. Two patients (8%) with a grade IIB injury were treated conservatively only with somatostatine without drainage. Eighteen (72 %) children underwent surgical intervention within 24 h after ERCP. Conclusion: ERCP is helpful when there is suspicion of pancreatic duct injury in order to exclude ductal leakage and the possibility of therapeutic intervention. ERCP can speed up diagnosis of higher grade of pancreatic injuries.

Generating the bounded derived category and perfect ghosts

We show, for a wide class of abelian categories relevant in representation theory and algebraic geometry, that the bounded derived categories have no non-trivial strongly nitely generated thick subcat- egories containing all perfect complexes. In order to do so we prove a strong converse of the Ghost Lemma for bounded derived categories.

Crohn's disease: Is there a place for neurological screening?

Abstract Objective. Neurological complications of inflammatory bowel diseases (IBDs) are not rare but are under-diagnosed; some are probably immune-mediated. Several previous studies have suggested a higher incidence of demyelinating diseases such as multiple sclerosis in IBD patients. In this single-center, prospective, observational study, the authors focus on T2 focal white-matter lesions of the central nervous system on magnetic resonance imaging (MRI) in IBD patients that may be due to demyelination. Material and methods. A total of 70 patients with Crohns disease were examined before beginning anti-TNF-α therapy. These patients were treated with azathioprine, mesalazine or both. Patients were examined by a neurologist to detect possible signs of demyelinating disease, and patients underwent brain MRI (native T1, T2, and FLAIR sequences). Results. Thirty-seven patients (53%) exhibited abnormalities on neurological examination, and 26 patients (37%) displayed abnormalities on MRI. In seven cases, these MRI abnormalities (periventricular lesions) were suspected to be due to demyelination. Cerebral spinal fluid investigation (including polyclonal bands) was completely negative in five cases and was borderline in one case, and multiple sclerosis was confirmed in one case. Pathological MRI findings in 19 other patients were clinically nonsignificant; most were nonspecific sporadic lesions in white matter or mild atrophy. Conclusions. The results support previous data that the frequency of neurological findings in IBD patients is generally underestimated. With the extension of biological anti-TNF-α treatment for IBD, the possibility of a higher risk of developing multiple sclerosis should be considered.

Gorenstein homological algebra and universal coefficient theorems

We study criteria for a ring—or more generally, for a small category—to be Gorenstein and for a module over it to be of finite projective dimension. The goal is to unify the universal coefficient theorems found in the literature and to develop machinery for proving new ones. Among the universal coefficient theorems covered by our methods we find, besides all the classic examples, several exotic examples arising from the KK-theory of C*-algebras and also Neeman’s Brown–Adams representability theorem for compactly generated categories.

Intestinal lymphangiectasia: A rare cause of gastrointestinal bleeding?

TO THE EDITOR: Primary intestinal lymphangiectasia is a rare cause of exudative enteropathy. Symptoms include diarrhoea, peripheral oedema, lymph oedema of the limbs, malaise and weight loss. A 25year-old female was admitted to our hospital because of gastrointestinal bleeding, which had occurred after blunt trauma of the abdomen. The endoscopic procedures (gastroscopy, push enteroscopy, wireless capsule) showed oedematous mucosa with scattered white spots, white villi, chyle-like matter covering the mucosa and diffuse bleeding of the small intestine. The other procedures (lymphoscintigraphy, lymphography) showed a picture of hyperplasia and dysplasia of the lymphatic vessels. In accordance with these investigations the final diagnosis of primary intestinal lymphangiectasia was established. The patient was treated with an middle chain triglycerids (MCT) enriched diet, lanreotide and, finally, by tranexamic acid. During therapy, there was a decrease in loss of blood and proteins. However, other complications occurred during the treatment (chylothorax, respiratory failure, recurrent sepsis, thrombosis of vena cava superior). The patient is still hospitalized in the intensive care unit, and her prognosis remains uncertain. Bleeding of the gastrointestinal tract as the main symptom of this disease is rarely described. There are few studies on the treatment of primary intestinal lymphangiectasia, most of them being case studies. The effectiveness of an MCT enriched diet along with a decrease in consumption of other fats has been described. In cases of disease limited to just part of the small intestine, surgical resection is usually the treatment of choice. Some investigators described good effects of steroids in patients with increased acute inflammatory markers. Other papers described the efficacy of using somatostatin analogues. In our patient, tranexamic acid as a somatostatin analogue led to a decrease in blood and protein loss. Despite treatment of symptoms, the prognosis of patients with primary intestinal lymphangiectasia remains uncertain. The rare incidence and heterogeneity of patients make it difficult to gain a better understanding of this disease.

The role of endoscopic retrograde cholangiopancreatography in choledochal cysts and/or abnormal pancreatobiliary junction in children

Introduction Biliary cysts with an abnormal pancreatobiliary junction are one of the most common pancreatobiliary malformations. The main symptom is cholestasis; endoscopic retrograde cholangiopancreatography (ERCP) plays a key role in diagnosis. Aim Retrospective evaluation of ERCP performed to diagnose abnormalities of the pancreatobiliary junction. Material and methods We retrospectively evaluated ERCP performed to diagnose abnormalities of the pancreatobiliary junction, mainly choledochal cysts, in 112 children between 1990 and 2011. Results We performed 112 examinations of 50 children with abnormal pancreatobiliary junction and choledochal cysts (15 males and 35 females, average age: 5 years, range: 1 month – 15 years). Cysts were associated with a common channel in 37 (74%) cases, were not associated with a common channel in 9 (18%) cases, and in 3 (6%) cases the common channel lacked cysts. We performed endoscopic papilla sphincterotomy on 33 (66%) patients; endoscopic drainage was performed 62 times, including 17 patients without papilla sphincterotomy. In 15 (30%) cases, we only performed sphincterotomy. Extraction of lithiasis was done in 2 (4%) cases. Both ERCP and magnetic resonance cholangiopancreatography (MRCP) were performed on 13 patients. There was concordance of the choledochal cyst and of the type of cyst in both methods; however, common channels could not be observed by MRCP. There was 1 serious complication (perforation after sphincterotomy) and 11 (9%) mild adverse events. Conclusions When performed at an expert centre, ECRP is a safe and reliable procedure for children with choledochal cysts and/or an abnormal pancreatobiliary junction. Endoscopic retrograde cholangiopancreatography remains a reasonable alternative because MRCP has a limited ability to diagnose the precise anomalies of the pancreatobiliary junction and has no therapeutic capabilities.

Endoscopic treatment of bile duct post-traumatic and post-operative lesions in children

Abstract Background and study aims: The aim of this study was to assess the significance and safety of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating bile duct injuries in children. Patients and methods: Fourteen pediatric patients, with traumatic or postoperative bile duct injury, in which ERCP was performed, were retrospectively evaluated. Results: We performed 46 ERCP and 12 endoscopic papillotomies in children with suspected bile duct injuries. A bile stent was primarily inserted in 13 patients and there were 20 replacements. Endoscopic treatment of bile leakage without need for bile duct sutures or reconstruction was successful in 85.7%. Post ERCP complications included cholangitis and recurrent bleeding, which occurred only in two patients each. Conclusions: ERCP and endoscopic bile stent insertion is a highly effective, minimally-invasive treatment for bile duct injury and should be included as part of the therapeutic procedures in pediatric patients with suspected bile duct injury.

Mutually unbiased bases as submodules and subspaces

Mutually unbiased bases (MUBs) have been used in several cryptographic and communications applications. There has been much speculation regarding connections between MUBs and finite geometries. Most of which has focused on a connection with projective and affine planes. We propose a connection with higher dimensional projective geometries and projective Hjelmslev geometries. We show that this proposed geometric structure is present in several constructions of MUBs.