Crushing Stones: Mechanical, Intracorporeal and Extracorporeal Lithotripsy in the Clearance of Common Bile Duct Lithiasis

Mechanical, intracorporeal and extracorporeal lithotripsy were used in the treatment of common bile duct lithiasis in a series of 80 patients in whom initial extraction attempts with the Dormia basket and balloon catheter failed. Mechanical lithotripsy was performed in 74 cases and was successful in 38 (51.3%). Among the 36 patients with failure of mechanical lithotripsy, five had an initial attempt at stone dissolution w1th methyl terr-butyl ether (MTBE) infused through a nasobiliary stent. This was successful in four cases; the stones did not disappear completely - however, they were smaller and easier to extract. Of the remaining 32 patients who failed mechanical lithotripsy, two underwent success[, l surgical stone extraction with no further attempts at nonoperative treatment and 30 underwent complementary shock wave lithotripsy. Extracorporeal lithotripsy was used in 19 of these patients. The intracorporeal lithotripsy group of21 patients comprised 11 with failed mechanical lithotripsy, six in whom no ocher treatment was attempted and four in whom extracorporeal lithotripsy had failed. Extracorporeal lithotripsy was successful in 15 cases (79%) and intracorporeal lithotripsy in 19 (90%). There were four treatment failures, with one patient death due to cholangitis and respiratory failure. In summary, mechanical lithotripsy is an effective and safe treatment modality but has a high failure rate. Extracorporeal lithotripsy is useful and should he attempted where available, but is not always successful. Intracorporeal lithotripsy is very efficient but requires either the transpapillary route, which is technically difficult, or the transhepatic route which carries associated complications

Identification and Characterization of Microsporidia from Fecal Samples of HIV-Positive Patients from Lagos, Nigeria

BACKGROUND: Microsporidia are obligate intracellular parasites that infect a broad range of vertebrates and invertebrates. They have been increasingly recognized as human pathogens in AIDS patients, mainly associated with a life-threatening chronic diarrhea and systemic disease. However, to date the global epidemiology of human microsporidiosis is poorly understood, and recent data suggest that the incidence of these pathogens is much higher than previously reported and may represent a neglected etiological agent of more common diseases indeed in immunocompetent individuals. To contribute to the knowledge of microsporidia molecular epidemiology in HIV-positive patients in Nigeria, the authors tested stool samples proceeding from patients with and without diarrhea. METHODOLOGY/PRINCIPAL FINDINGS: Stool samples from 193 HIV-positive patients with and without diarrhea (67 and 126 respectively) from Lagos (Nigeria) were investigated for the presence of microsporidia and Cryptosporidium using Weber's Chromotrope-based stain, Kinyoun stain, IFAT and PCR. The Weber stain showed 45 fecal samples (23.3%) with characteristic microsporidia spores, and a significant association of microsporidia with diarrhea was observed (O.R. = 18.2; CI: 95%). A similar result was obtained using Kinyoun stain, showing 44 (31,8%) positive samples with structures morphologically compatible with Cryptosporidium sp, 14 (31.8%) of them with infection mixed with microsporidia. The characterization of microsporidia species by IFAT and PCR allowed identification of Enterocytozoon bieneusi, Encephalitozoon intestinalis and E. cuniculi in 5, 2 and 1 samples respectively. The partial sequencing of the ITS region of the rRNA genes showed that the three isolates of E.bieneusi studied are included in Group I, one of which bears the genotype B. CONCLUSIONS/SIGNIFICANCE: To our knowledge, this is the first report of microsporidia characterization in fecal samples from HIV-positive patients from Lagos, Nigeria. These results focus attention on the need to include microsporidial diagnosis in the management of HIV/AIDS infection in Nigeria, at the very least when other more common pathogens have not been detected

Crushing Stones: Mechanical, Intracorporeal and Extracorporeal Lithotripsy in the Clearance of Common Bile Duct Lithiasis

Mechanical, intracorporeal and extracorporeal lithotripsy were used in the treatment of common bile duct lithiasis in a series of 80 patients in whom initial extraction attempts with the Dormia basket and balloon catheter failed. Mechanical lithotripsy was performed in 74 cases and was successful in 38 (51.3%). Among the 36 patients with failure of mechanical lithotripsy, five had an initial attempt at stone dissolution w1th methyl terr-butyl ether (MTBE) infused through a nasobiliary stent. This was successful in four cases; the stones did not disappear completely - however, they were smaller and easier to extract. Of the remaining 32 patients who failed mechanical lithotripsy, two underwent success[, l surgical stone extraction with no further attempts at nonoperative treatment and 30 underwent complementary shock wave lithotripsy. Extracorporeal lithotripsy was used in 19 of these patients. The intracorporeal lithotripsy group of21 patients comprised 11 with failed mechanical lithotripsy, six in whom no ocher treatment was attempted and four in whom extracorporeal lithotripsy had failed. Extracorporeal lithotripsy was successful in 15 cases (79%) and intracorporeal lithotripsy in 19 (90%). There were four treatment failures, with one patient death due to cholangitis and respiratory failure. In summary, mechanical lithotripsy is an effective and safe treatment modality but has a high failure rate. Extracorporeal lithotripsy is useful and should he attempted where available, but is not always successful. Intracorporeal lithotripsy is very efficient but requires either the transpapillary route, which is technically difficult, or the transhepatic route which carries associated complications

Cutting the Difficult Papilla: Ancillary Techniques in the Performance of Endoscopic Sphincterotomy

Of 1040 endoscopic sphincterotomies performed over a five year period, standard papillotomy was possible in 874 (84%). In 166 cases (16%) a difficult papilla was encountered requiring nonstandard techniques of precutting, transpapillary guided endoscopic sphincterotomy, transhepatic guided endoscopic sphincterotomy and percutaneous transhepatic sphincterotomy. The technique first attempted in these 166 cases was successfully completed in 154 (93%). Among the 135 cases with intradiverticular papillas, successful papillotomy was achieved in 125 (92.7%). Early complications of standard endoscopic sphin-.lerotomy included bleeding, perforation, pancreatitis and cholangitis, comprising 4.3% of the 1040 sphincterocomies. There were five deaths (mortality rate 0.5%) and laparotomy was required in six patients (0.6%). Conditions contributing to complications included an intradiverticular papilla and precutting. Evaluation of endoscopic sphincterotomy by transpapillary or transhepatic routes guided by guidewire or drain placement revealed complication rates of 6.6 and 10.6%, respectively. Of the patients with histories of gastric resection and Billroth II anastomoses, standard sphincterotomy was possible in 15 (55.5%); in two cases the papilla was unapproachable endoscopically, requiring use of percutaneous transhepatic sphincterotomy. The percutaneous transhepatic sphincterotomy without endoscopic control is felt to be a higher risk procedure and should be reserved for rare indications. Appropriate use of these techniques should allow performance of endoscopic sphincterotomy in almost all clinical settings

Detection and species identification of intestinal microsporidia by polymerase chain reaction in duodenal biopsies from human immunodeficiency virus-infected patients

Polymerase chain reaction (PCR) was used for the detection of microsporidian DNA in duodenal biopsies obtained from 28 human immunodeficiency virus (HIV)-infected patients with intestinal microsporidiosis. Duodenal biopsies from 23 HIV-infected patients without microsporidiosis served as controls. A generic primer set for human microsporidia was used at first for the PCR. Amplified products were detected in 26 (93%) of 28 biopsies from patients with intestinal microsporidiosis. All control biopsies were negative. Microsporidia species were identified using Southern blot hybridization with specific probes for Enterocytozoon bieneusi and Encephalitozoon intestinalis. This technique confirmed the transmission electron microscopy-based species identification. Similar results were obtained using PCR with species-specific primer sets for E. bieneusi and E. intestinalis. PCR testing of intestinal biopsy specimens can be used successfully for rapid detection and species differentiation of intestinal microsporidia and thus could be a valuable alternative to transmission electron microscop

Diagnosis and prognosis of AIDS-related cholangitis.

International audienceOBJECTIVE: To determine more precisely the clinical and biological characteristics of AIDS-related cholangitis, and to investigate prognostic variables of this disease. DESIGN: Retrospective clinical and prognostic study. SETTING: Biliary unit, Bicêtre Hospital, France. PATIENTS: HIV-positive patients (n = 52) referred to the unit between December 1986 and June 1993 for biliary symptoms leading to the suspicion of AIDS-related cholangitis, (42 men; 10 women; mean age, 37 +/- 8 years). INTERVENTION: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in order to determine the cause of the biliary symptoms. MAIN OUTCOME MEASURE: Clinical features and evolution of the cholangitis. RESULTS: Among the 52 patients, 45 met the ERCP criteria of AIDS-related cholangitis (36 men; nine women). The diagnosis of cholangitis was strongly suggested by abdominal ultrasonography in 47% of the cases. ERCP showed papillary stenosis, diffuse cholangitis, extrahepatic cholangitis alone, and intrahepatic cholangitis alone in 60, 67, 7 and 27%, respectively. Endoscopic sphincterotomy was performed in 28 patients. Pain was relieved by sphincterotomy in nine patients, but the other clinical or biological features were not influenced. One-year and 2-year survival rates were 41 +/- 7% and 8 +/- 4%, respectively. Multidimensional analysis using a Cox model showed that a lymphocyte count > 500 x 10(6)/l was the only independent predictive factor of better survival. CONCLUSION: AIDS-related cholangitis is a disease which leads preferentially to papillary stenosis or diffuse abnormalities of the biliary tract. Prognostic factors depend on the stage of the HIV infection. Another diagnosis of cholestasis was found in approximately 15% of the patients who showed biliary symptoms