| A 78-year-old woman was admitted for recurrent jaundice, fever and biliary colic. At operation the common duct was found to be filled with a large blood clot. Removal of this clot resulted in a clinical cure. ( info) |
12/298. Alpha-1-antitrypsin deficiency and liver in adults. Thirteen adult patients (aged 16 to 73 years) form 12 families are described with liver disease and alpha- 1- antitrypsin deficiency. Long-term observation of several of these patients suggests that the liver disease may be only slowly progressive, but review of possible factors aggravating this has failed to reveal any obvious clues. Progression to death from hepatic failure was the commonest outcome, but one patient developed a malignant hepatoma and two others died because of intraperitoneal haemorrhage due to ruptured cirrhotic nodules--a complication not hitherto described in association with this condtion. diagnosis of alpha-1-antitrypsin deficiency was based on serological, histological, immunopathological and genetic studies. The most useful screening test in liver disease was found to be the demonstration of PAS positive globules in liver biopsy material which is diagn by immunofluoresence or immunoperoxidase, the latter being a superior technique. serum estimation of alpha-1 -antitrypsin deficiency was performed by immunoelectropharetic and immunodiffusion techniques, the former being preferred because it gave more consistent results. Both methods, however, were of limited value since wide variations in the serum values are commonly found in normal and abnormal states. Genotyping was carried out using starch gel electrophoresis and although of value in family studies, its value as a diagnositc aid is limited because of technical difficulties and also because alpha-1-antitrypsin accumulation in the liver may be found in both homozygous and heterozygous states. It is suggested that adult liver disease associated with abnormalities in alpha-1-antitrypsin may be more common than has hitherto been reported. This condition should be systematically sought in all cases of liver disease of uncertain aetiology. ( info) |
13/298. Pethidine reverses morphine-induced delirium. A young patient had unexpected and prolonged postoperative delirium apparently associated with morphine-induced biliary colic. naloxone had no therapeutic effect, but a small dose of pethidine produced a dramatic return to lucidity. Unrecognized biliary spasm should be considered as a cause of agitation in the recovery room in postoperative patients who have received morphine. ( info) |
14/298. Medial indentation of the duodenal sweep by common bile duct dilatation. The dilated common bile duct has long been recognized as a cause for a smooth, tubular impression across the duodenal bulb or immediate postbulbar duodenum. Only scattered references suggest that a smooth indentation on the medial aspect of the descending duodenum might also be due to an enlarged, tortuous common duct. Three cases of this condition are reported. The dilated common duct impression can mimic a pancreatic mass. While computed tomography, ultrasonography, or transhepatic cholangiography readily suggest the true diagnosis, potential pitfalls in patient management are possible when the first radiographic procedure is an upper gastrointestinal series. ( info) |
15/298. Biliary cysts. This review brings the total number of biliary cysts reported in the world literature to 955. Eighty-one per cent of patients are females and 61% were discovered before age ten. The classical triad of right upper quadrant pain, right upper quandrant mass, and juandice is present in 38% of cases. The duration of symptoms prior to diagnosis ranged from less than one week to more than 40 years. The etiology is multifaceted and evidence of the existence of both acquired and congenital cysts is presented. The most useful diagnostic tool is fiberoptic endoscopy with retrograde contrast injection of the common bile duct and pancreatic duct. The incidence of biliary carcinoma in patients with biliary cysts is found to be 2.5%; 24 cases have been reported. Considerable controversy has existed concerning the best operative procedure for biliary cysts; no treatment or medical treatment yielding a 97% mortality rate. In an analysis of 235 patients presented since 1968 with an average followup of 5.2 years, the best procedure appears to be excision with either choledochocholedocostomy or Roux-en-Y hepaticojejunostomy. The operative mortality for all procedures is now 3 to 4%. ( info) |
16/298. Vaterian diverticula as a cause of acute pancreatitis. The association of duodenal diverticula and pancreatitis is rare. Various types of such diverticula are reviewed, especially intra- and extraluminal Vaterian diverticula in which common and pancreatic duct terminate. The pathogenesis of the pancreatitis in case of interposed Vaterian diverticula is thought to be mechanical by means of the creation of a closed Vaterian pouch in which higher pressures produce reflux of bile and pancreatic enzymes. Two patients with this particular type of duodenal diverticula are presented. ( info) |
| We present a case of rupture of an intrahepatic choledochal cyst through the diaphragm resulting in a pleuro-biliary fistula and a right pleural empyema which was surgically treated. Hepatobiliary complications resulting in biliary empyema of the pleura are discussed. ( info) |
18/298. Three common presentations of ascariasis infection in an urban Emergency Department. In the united states, approximately 4 million people per year are infected with ascaris lumbricoides. We reviewed the common presentations of complications of ascariasis infection in the Emergency Department (ED) and the diagnostic tools and treatment available. This was a retrospective case review conducted on all patients diagnosed with ascariasis (using ICD-9 codes) over a 6-year period at los angeles County and University of Southern california Medical Center. Three patients with distinct complications secondary to ascariasis were chosen, and all ED and inpatient records were reviewed. The patient's age, sex, race, presenting symptoms, data, outcome, and ED course and diagnosis were recorded. The three cases included a periappendiceal abscess, Loeffler's syndrome, and biliary colic/choledocholithiasis. The first patient underwent a computed tomography-guided drainage of the abscess. The second patient received supportive care and antibiotic therapy secondary to a superimposed bacterial pneumonia. The third patient underwent endoscopic retrograde cholangiopancreatography with sphincterotomy. All three patients had a stool ova and parasites positive for A. lumbricoides, and all received a 3-day course of mebendazole. Symptomatic cases of ascariasis may present to EDs in the united states. Important diagnostic tools for the ED include chest X-ray, X-ray of the kidney-ureter-bladder and ultrasonography. Single-dose medications given in the ED are very effective in eradicating A. lumbricoides infection, thus avoiding hospitalization. ( info) |
19/298. Bilo-pancreatic ascaris lumbricoides infestation. Endoscopic discovery and removal. ascaris lumbricoides infestation is relatively rare in industrialized countries, and it occurs mainly in conditions in which hygiene is lacking. We describe here a case of a 39-year-old female from ex-Jugoslavia affected by recurrent hepatic colic. At entry ultrasonography revealed microlithiasis in the gallbladder and widening of the pancreatic head. The subsequent ERCP showed slight filling defects in the choledochus and an inflammation-like stricture of the papilla of Vater, and after endoscopic sphincterotomy we saw an outflow of dense bile and microlitholits. Thus, a standard surgical cholecystectomy was carried out and the patient was dismissed on the 3rd postoperative day without any symptoms. However, the patient was admitted again after four days for a new coliky pain attack. An upper endoscopy showed a 23 cm long mobile parasite in the duodenum: it was caught with the polypectomy loap, extracted and identified as A. Lumbricoides. The patient's symptoms disappeared after the endoscopic removal of the worm and she was dismissed the day after the worm's removal. No recurrence of symptoms was noted during a 1-year follow-up. This case showed that A. Lumbricoides infestation of the biliary tree should be considered when biliary and/or pancreatic symptoms recur, especially in patients coming from undeveloped countries. At the same time we showed that endoscopic removal is a safe and effective treatment for this infestation. ( info) |
20/298. Bile duct biopsy with the stone extraction basket. Case report. The stone extraction basket is suitable for biopsy of protruding mucosal lesions in the biliary duct system. Exact placement of the instrument over the lesion is readily accomplished under roentgenologic control. The technique is illustrated in one patient with biopsy of an iatrogenic mucosal tag in the distal common duct. ( info) |