Ectopic opening of the common bile duct and duodenal stenosis: an overlooked association

<p>Abstract</p> <p>Background</p> <p>Ectopic opening of the common bile duct into the duodenal bulb (EO-CBD-DB) is a rare disease that may be complicated by duodenal ulcer, deformity, stenosis and biliary stones. The aim of this study is to report clinical presentations, endoscopic diagnosis and treatment of this entity as well as to investigate its association with duodenal stenosis.</p> <p>Methods</p> <p>Gastroduodenoscopic findings and radiological imaging were evaluated for ectopic papilla and duodenal stenosis. Diagnostic methods, endoscopic procedures and long-term outcomes of the endoscopic treatment were presented.</p> <p>Results</p> <p>EO-CBD-DB was found in 74 (77.1%) of the 96 patients with duodenal deformity/stenosis (79 male, 17 female, mean age: 58.5, range: 30-87 years). The papilla with normal appearance was retracted to the bulb in 11 while it was at its usual location in the remaining 11. The history of biliodigestive surgery was more common in patients with EO-CBD-DB who were frequently presented with the common bile duct stone-related symptoms than the other patients. Thirteen (17.6%) of the patients with EO-CBD-DB were referred to surgery. Endoscopic treatment was completed in 60 (81.1%) patients after an average of 1.7 (range: 1-6) procedures. These patients were on follow-up for 24.8 (range: 2-46) months. Endoscopic intervention was required in 12 (20%) of them because of recurrent biliary problems. Treatment of the patient who had stricture due to biliary injury during laparoscopic cholecystectomy is still continued.</p> <p>Conclusions</p> <p>The presence of EO-CBD-DB should be considered particularly in middle-aged male patients who have duodenal deformity/stenosis. Endoscopic treatment is feasible in these patients. The long-term outcomes of endoscopic therapy need to be compared with surgical treatment.</p

Mineral chemistry of barium- and titanium-bearing biotites in calc-alkaline volcanic rocks from the Mezitler area (Balιkesir-Dursunbey), western Turkey

Barium- and titanium-bearing biotites from Miocene volcanic rocks of Mezitler area, eastern Balιkesir, western Turkey are studied. The chemical composition of volcanic rocks range from andesite to rhyodacite. The iron-enrichment index of micas (average I.E. = 0.40) is intermediate between annite and phlogopite. The biotite phenocrysts contain up to 1.72 wt.% BaO and 5.90 wt.% TiO2, with the average formulae (K0.807 Na0.131 Ca0.036 Ba0.027) (Mg1.404 Fe2+ 0.800 Fe3+ 0.131 Ti0.303 Al0.056 Mn0.023) (Si2.832 Al1.167) O10 [(OH)1.976 Cl0.024]. The BaO content of electron-microprobe micas is positively correlated with the Al2O3, TiO2, and FeO contents, and with the I.E., and is negatively correlated with the SiO2, K2O, and MgO contents. Ba and Ti-rich micas are generally found in potassic igneous rocks, in subalkaline and alkaline gabbroic rocks and in contact metamorphic rocks, whereas Ba- and Ti-bearing micas in this study occur in calc-alkaline volcanic rocks that hosted manganese-oxide and barite deposits. Most of the phenocrysts analyzed have deficiencies in their octahedral and partly interlayer sites. Deficiencies in the octahedral sites may arise from the Ti-vacancy and partly the Ti-tschermakite substitution. On the other hand, deficiencies in the interlayer-site are due to the replacement of K by Ba. The substitution mechanism in the Mezitler micas is characterized by Ba + 2Ti + 3Al = (K+Na+Ca) + 3(Mg+Fe+Mn) + 3Si, with an excellent correlation coefficient. In terms of aluminum and titanium contents, micas from the Mezitler area lie on a similar trend parallel to that for metasomatic phlogopites from Canary Island xenoliths, which overlap the field for micas from the Ilha da Trindade xenolith, South Atlantic. Biotite compositions from the Mezitler area fall between the quartz-fayalite-magnetite (QFM) and nickel-nickel oxide (NNO) oxygen fugacity buffers. All these show that Mezitler micas with low to moderate Ba- and Ti-contents may be formed from magmas in a subduction-enriched sub-continental lithospheric mantle environment

Fatal rhinocerebral mucormycosis under the shade of hepatic encephalopathy

Mucormycosis is an acutely fatal infection that occurs in immuncompromised patients. Cirrhosis is an acquired immune deficiency state and those patients are more prone to develop opportunistic infections. A 42-years-old cirrhotic man was admitted to our gastroenterology clinic with hepatic encephalopathy. Although he recovered from encephalopathy with supportive measurements, he developed paresthesia on the face. He was diagnosed with rhinocerebral mucormycosis and antifungal therapy was administered. Surgical treatment couldn’t be performed because of his bleeding diathesis and poor general condition. He succumbed on the 12th day of his admission

A Simple Method to Improve Adenoma Detection Rate During Colonoscopy: Altering Patient Position

BACKGROUND: Colonoscopy is currently considered to be the gold standard method for detecting and removing adenomatous polyps. However, tandem colonoscopy studies reveal a pooled polyp miss rate of 22%

A Simple Method to Improve Adenoma Detection Rate During Colonoscopy: Altering Patient Position

BACKGROUND: Colonoscopy is currently considered to be the gold standard method for detecting and removing adenomatous polyps. However, tandem colonoscopy studies reveal a pooled polyp miss rate of 22%

Major predictors for difficult common bile duct stone

Giriş ve Amaç: Safra kanalı taşlarının tedavisinde endoskopik retrograd kolanjiopankreatografi standard tedavi haline gelmiş- tir. Bu hastalarda endoskopik retrograd kolanjiopankreatografinin teknik güçlüğünü araştıran küçük hasta grupları ile yapılmış az sayıda çalışma vardır. Bu çalışmada biz bu faktörleri geniş bir hasta grubunda araştırmayı amaçladık. Gereç ve Yöntem: İki yıllık bir süre içerisinde endoskopik retrograd kolanjiopankreatografi yapılan tüm naive hastalar (n=1850) prospektif olarak değer- lendirildi. Taş çıkartmak için birden fazla endoskopik retrograd kolanjiopankreatografi seansı, mekanik litotripsi, ekstra şok dal- ga litotripsi gerektiren yada endoskopik olarak çıkarılamayıp cerrahiye giden hastalar zor taşı olan hastalar olarak kabul edildi. Yaş, cinsiyet, labaratuvar parametreler, endoskopik ve kolanjiografik bulgular kayıt edildi. Zor için prediktif faktörler univariate ve multivariate analizlerle araştırıldı. Bulgular: Çalışma grubu oralama 60±16 yaşında 432 kadın 325 erkek hastadan oluştu. 757 hastanın 654'ünde (%86.4) kolay taş, 103'ünde (%13.6) zor taş var idi. Hastaların %98.1'inde endoskopik taş çıkarma işlemi başarılı idi. Taşın ötesinde darlık olması (OR: 8.248), küçük ortak safra kanalı/taş çapı oranı (OR: 0.348), taş çapı (OR: 1.187), taşın impakte olması (OR: 1.117) ve yüksek bilirubin değerleri (OR: 1.1) zor taş için multivariate analizde bağımsız belir- leyici faktörler olarak tespit edildi. Sonuç: Ortak safra kanalı taşları tedavisinde endoskopik retrograd kolanjiopankreatografi çok etkili bir yöntemdir. Taşın ilerisinde darlık olmasının yanında küçük safra kanalı/taş çapı oranı, taş çapı, impakte taş ve yüksek bilirubin değerleri zor taş için önemli belirteçlerdir.Background/aims: Endoscopic retrograde cholangiopancreatography has become the standard treatment for common bile duct stones worldwide. There are only a few reports with small number of patients concerning the factors that contribute to the techni- cal difficulty of endoscopic retrograde cholangiopancreatography in these patients. In this study, we aimed to investigate these fac- tors in a large group of patients. Materials and Methods: All patients with naive papilla (n=1850) who underwent endoscopic ret- rograde cholangiopancreatography during a study period of 2 years were prospectively evaluated. Among them, 757 patients with common bile duct stones were included in the study. Following successful cannulation, the patients who needed either more than one episode for stone extraction or mechanical lithotripsy, extracorporeal shock wave lithotripsy or in whom stone extraction could not be achieved endoscopically and underwent surgery were regarded as having -difficult stones-. Age, sex, laboratory parameters, endoscopic and cholangiographic findings were recorded in all patients. Predictive factors for difficult stones were investigated in univariate and multivariate analysis. Results: The study group consisted of 432 women and 325 men with a mean age of 60±16 ye- ars . Of the total 757 patients, 654 (86.4%) had easy and 103 (13.6%) had difficult stones. Endoscopic stone extraction was successful in 98.1% of patients. Stricture distal to the stone (OR: 8.248), smaller common bile duct/stone diameter ratio (OR: 0.348), stone diameter (OR: 1.187), stone impaction (OR: 1.117), and higher bilirubin levels (OR: 1.1) were found to be independent predictors of difficult stone in multivariate analysis. Conclusion: Endoscopic retrograde cholangiopancreatography is a very effec- tive method for the treatment of common bile duct stones. Besides strictures distal to the stone, smaller common bile duct/stone di- ameter ratio, stone diameter, impacted stone, and higher bilirubin levels are significant predictors of difficult stone

Zor safra kanalı taşının en Önemli belirteçleri

Giriş ve Amaç: Safra kanalı taşlarının tedavisinde endoskopik retrograd kolanjiopankreatografi standard tedavi haline gelmiş- tir. Bu hastalarda endoskopik retrograd kolanjiopankreatografinin teknik güçlüğünü araştıran küçük hasta grupları ile yapılmış az sayıda çalışma vardır. Bu çalışmada biz bu faktörleri geniş bir hasta grubunda araştırmayı amaçladık. Gereç ve Yöntem: İki yıllık bir süre içerisinde endoskopik retrograd kolanjiopankreatografi yapılan tüm naive hastalar (n=1850) prospektif olarak değer- lendirildi. Taş çıkartmak için birden fazla endoskopik retrograd kolanjiopankreatografi seansı, mekanik litotripsi, ekstra şok dal- ga litotripsi gerektiren ya da endoskopik olarak çıkarılamayıp cerrahiye giden hastalar zor taşı olan hastalar olarak kabul edildi. Yaş, cinsiyet, labaratuvar parametreler, endoskopik ve kolanjiografik bulgular kayıt edildi. Zor için prediktif faktörler univariate ve multivariate analizlerle araştırıldı. Bulgular: Çalışma grubu oralama 60±16 yaşında 431 kadın 325 erkek hastadan oluştu. 757 hastanın 654'ünde (86,4%) kolay taş, 103'ünde (13,6%) zor taş var idi. Hastaların %98,1'inde endoskopik taş çıkarma işlemi başarılı idi. Taşın ötesinde darlık olması (OR: 8,248), küçük ortak safra kanalı/taş çapı oranı (OR: 0,348), taş çapı (OR: 1,187), taşınstone impakte olması (OR: 1,117) ve yüksek bilirubin değerleri (OR: 1,1) zor taş için multivariate analizde bağımsız be- lirleryici faktörler olarak tespit edildi. Sonuç: Ortak safra kanalı taşları tedavisinde endoskopik retrograd kolanjiopankreatogra- fi çok etkili bir yöntemdir. Taşın ilerisinde darlık olmasının yanında küçük safra kanalı/taş çapı oranı, taş çapı, impakte taş ve yüksek bilirubin değerleri zor taş için önemli belirteçlerdirBackground/aims: Endoscopic retrograde cholangiopancreatography has become the standard treatment for common bile duct stones worldwide. However, there are only a few reports with small number of patients concerning the factors that contribute to the technical difficulty of endoscopic retrograde cholangiopancreatography in these patients. In this study we aimed to investigate these factors in a large group of patients. Materials and Methods: All patients with a naıïve papilla (n=1850) who underwent endoscopic retrograde cholangiopancreatography during a study period of 2 years were prospectively evaluated. Of these, 757 patients with com- mon bile duct stones were included in the study. Following successful cannulation, patients who needed either more than one episode for stone extraction or mechanical lithotripsy, extracorporeal shock wave lithotripsy, or patients in whom stone extraction could not be achieved endoscopically and underwent surgery were regarded as having “difficult stones”. Age, sex, laboratory parameters, endo- scopic and cholangiographic findings were recorded in all patients. Predictive factors for difficult stones were investigated using univariate and multivariate analysis. Results: The study group consisted of 432 women and 325 men with a mean age of 60±16 years . Of the total 757 patients, 654 (86.4%) had easy and 103 (13.6%) had difficult stones. Endoscopic stone extrac- tion was successful in 98.1% of patients. A stricture distal to the stone (OR: 8.248), smaller common bile duct/stone diameter ratio (OR: 0,348), stone diameter (OR: 1,187) stone impaction (OR: 1,117) and higher bilirubin levels (OR: 1,1) were found to be inde- pendent predictors of difficult stone extraction on multivariate analysis. Conclusion: Endoscopic retrograde cholangiopancreatog- raphy is a very effective method for the treatment of common bile duct stones. Presence of a stricture distal to the stone, smaller com- mon bile duct/stone diameter ratio, stone diameter, impacted stone, and higher bilirubin levels are significant predictors of diffi- cult ston