Duct Obstruction Research Articles

S1567 Pancreatico-Pleural and Enteric Fistulas: A Rare Complication of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

INTRODUCTION: Pancreatico – pleural and enteric fistulas (PPEF) are rare complications of pancreatitis, where a tract is created draining pancreatic fluid into the pleural cavity and/or bowel. Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a 5-10% risk of pancreatitis. CASE DESCRIPTION/METHODS: A 66-year-old female with past medical history of hypertension and asthma presented for abdominal pain with nausea and vomiting. One-day prior she underwent an ERCP. She was treated conservatively for post-ERCP (pERCP) pancreatitis. Subsequently she was admitted for pancreatitis three times over a period of 3 months. Vitals were within normal limits. Physical examination was significant for diffuse abdominal tenderness and normoactive bowel sounds. Laboratory data was significant for a lipase of 2858, and a WBC of 12.39. Otherwise, complete metabolic panel, and CBC were normal. Initial computerized tomography (CT) showed acute pancreatitis with a large pseudocyst (Figure 1). Interval CT showed pancreatic duct dilation, a pancreatico-enteric fistula tract and a new left pleural effusion with air within the fluid suggestive of a pancreatico-pleural fistula (Figure 2). The patient was managed conservatively. At 3-month follow up, the patients symptoms had resolved, and a repeat CT showed resolution of pancreatitis, fistula and pleural effusion (Figure 3). DISCUSSION: Magnetic resonance cholangiopancreatography is the diagnostic imaging of choice for visualizing pancreatic fistulas. Thoracentesis with a lipase-rich pleural fluid can help aid in the diagnosis.Modalities of treatment are endoscopic stenting of the disrupted pancreatic duct, conservative management with octreotide (to suppress pancreatic exocrine function) with or without chest tube drainage, or surgical intervention with distal pancreatectomy and pancreatico-jejunostomy in those with complete ductal obstruction. Thirty to 60% of patients can be managed successfully with conservative management. Sphincter of oddi dysfunction, young age, repeated cannulation attempts with sphincterotomy, and history of pancreatitis are risk factors for pERCP pancreatitis. Prophylactic rectal indomethacin and pancreatic stenting in patients at high risk of pERCP pancreatitis have been shown to decrease incidence rates. PPEF uncommonly arise together and require a high index of suspicion. The diagnosis can be made via imaging, endoscopy or with a thoracentesis. Management is usually conservative, but endoscopic or surgical procedures may be warranted.Figure 1.: CT abdomen and pelvis showing acute pancreatitis with a pancreatic tail/body large pseudocyst (Green arrow).Figure 2.: Interval CT Chest, abdomen and pelvis showing dilated pancreatic duct (Blue arrow), resolving pancreatic pseudocyst(White arrow), pancreatico-enteric fistula tract (Red arrow), and a new left pleural effusion with air within the fluid (Yellow arrow) suggestive of a pancreatico-pleural fistula.Figure 3.: A 3-month Interval CT abdomen, pelvis and chest showing complete resolution of acute pancreatitis and fistula tract (Panel A), and resolution of pleural effusion (Panel B).

S3070 Severity of Biliary Pancreatitis in Hispanics vs Non-Hispanics: Are There Any Differences?

INTRODUCTION: Biliary pancreatitis manifests as pancreatic inflammation due to ductal obstruction by a stone at the sphincter of Oddi. Often presenting as acute-onset abdominal pain with elevated biochemical markers, it can be a life-threatening disease requiring urgent evaluation. Contrast-enhanced computed tomography (CT) identifies the presence and extent of pancreatitis necrosis, and the CT Severity Index (CTSI) is a reliable predictor of severity and mortality of acute biliary pancreatitis. Mortality due to biliary pancreatitis ranges from 3% in patients with interstitial edematous pancreatitis to 17% in those who develop pancreatic necrosis, demonstrating the need for early identification and intervention. This study compared the severity of disease in Hispanic and non-Hispanic patients based on the CTSI as well as the Revised Atlanta Classification for Acute Pancreatitis. METHODS: A retrospective analysis of 303 biliary pancreatitis cases in patients aged 18-80 years from 2012 to 2019 were reviewed. Initial CT findings were standardized by a single reader. Patients were excluded if they did not have a diagnosis of biliary pancreatitis or an initial CT scan on admission. Data was analyzed with R, using univariate and multivariable logistic regression and Fisher’s exact test. RESULTS: 185 patients (average age 53.5 years) were Hispanic, and 118 (average age 49 years) were non-Hispanic. 21/185 (11.4%) patients in the Hispanic group presented with a fluid collection on initial CT versus 19/118 (16.1%) non-Hispanic patients (P = 0.309). 9/185 (4.9%) Hispanics had an acute necrotic collection (ANC), compared to 6/118 (5.1%) non-Hispanics (P = 0.44). 8/185 (4.3%) Hispanics had an acute peripancreatic fluid collection (APFC) associated with interstitial edematous pancreatitis, compared to 10/118 (8.5%) non-Hispanics. 5 total patients presented with a pancreatic pseudocyst, of which 4 were Hispanic. The average CTSI score was 2.14 +/- 1.96 for non-Hispanics and 1.82 +/- 1.76 (P = 0.132) for Hispanics. CONCLUSION: No statistical differences were noted in severity of biliary pancreatitis based on imaging evaluation among the two groups. The absolute difference of patients with pancreatic pseudocyst suggests that Hispanics may have stayed home longer between the onset of symptoms and hospital admission. This is the first study to classify ethnic differences in severity based on CT imaging. Larger cohort population studies are necessary to determine if statistically significant differences are present or not.Table 1.: Patient DemographicsTable 2.: Presence/Type of Fluid Collection on CT Scan and CTSI in Hispanics versus Non-Hispanics

Clinical management of Sialadenitis

Within the area of salivary gland pathology, obstructive sialadenitis is the most common inflammatory condition of the salivary glands.1
 It has been well established in the literature that salivary calculi occur most commonly in the submandibular gland, whereas fewer cases are found in the parotid gland, while the sublingual gland and the minor salivary glands form no more than 2% of cases.2
 The early treatment of sialadenitis is usually conservative and involves hydration, anti inflammatory medication in conjunction to antibiotics when a bacterial infection is suspected. However, when initial treatment fails, further intervention is needed.
 The traditional external approach is sialadenectomy. However, with this exists the potential for injury to the lingual and facial nerves. Further complications including bleeding, infection and an unsightly scar are also found with this procedure.3,4
 Sialendoscopy is a relatively new technique that only became available once optics had improved to the extent that fiber-optic endoscopes could be miniaturized to a diameter of 0.9 mm to 1.6 mm. This has ushered in a new era for the management of sialadenitis, particularly in cases where sialadenitis was caused by salivary duct obstruction.
 It must be noted that in South Africa, there are currently no generally accepted guidelines on the management of sialadenitis secondary to salivary ductal obstruction as well as in the role of sialendoscopy within the treatment algorithm.

Therapeutic Instruments Targeting Meibomian Gland Dysfunction.

The most prevalent type of meibomian gland dysfunction (MGD), which is obstructive, is the main cause of evaporative dry eye and is characterized by changes in the meibum composition and duct obstruction. Eyelid hygiene has usually been the most common clinical approach. However, alternative therapies for MGD are emerging on the market. Some warming and humidity devices have led to an improvement in the signs and symptoms in MGD patients. Likewise, eyelid massaging and cleaning devices are also beneficial for ocular signs and symptoms; however, patients usually need more than one session to maintain the therapeutic effect. Thermal pulsation has been reported to be more efficient than other strategies, and the effects can last up to 12 months. Moreover, intense pulsed light therapy has been demonstrated to improve ocular signs and symptoms alone and in combination with other therapies. Proper counseling of clinicians considering MGD status and patient compliance will help patients to undergo the adequate technique that best suits their condition.

A tale of two pancreases: exocrine pathology and endocrine dysfunction.

The islets of Langerhans are well embedded within the exocrine pancreas (the latter comprised of ducts and acini), but the nature of interactions between these pancreatic compartments and their role in determining normal islet function and survival are poorly understood. However, these interactions appear to be critical, as when pancreatic exocrine disease occurs, islet function and insulin secretion frequently decline to the point that diabetes ensues, termed pancreatogenic diabetes. The most common forms of pancreatogenic diabetes involve sustained exocrine disease leading to ductal obstruction, acinar inflammation, and fibro-fatty replacement of the exocrine pancreas that predates the development of dysfunction of the endocrine pancreas, as seen in chronic pancreatitis-associated diabetes and cystic fibrosis-related diabetes and, more rarely, MODY type 8. Intriguingly, a form of tumour-induced diabetes has been described that is associated with pancreatic ductal adenocarcinoma. Here, we review the similarities and differences among these forms of pancreatogenic diabetes, with the goal of highlighting the importance of exocrine/ductal homeostasis for the maintenance of pancreatic islet function and survival and to highlight the need for a better understanding of the mechanisms underlying these diverse conditions. Graphical abstract.

Biliary Dilation: An Unusual Presentation of Histoplasma capsulatum in a Dog

ABSTRACT A 4 mo old intact male Labrador retriever was referred to the authors’ institution for a 3 wk history of weight loss and progressive abdominal distension. Thoracic radiographs revealed sternal lymphadenopathy and a diffuse unstructured interstitial and bronchial pulmonary pattern. An abdominal ultrasound revealed multifocal lymphadenopathy, hepatosplenomegaly, and biliary duct dilation. Fine-needle aspirates of the spleen and liver revealed Histoplasma capsulatum organisms. Antifungal therapy was initiated with itraconazole and terbinafine. Repeat ultrasound examinations revealed resolving hepatosplenomegaly and resolving cystic duct dilation. Ultrasonographic findings mirrored a decrease in urine H capsulatum antigen levels. Histoplasmosis should be considered as a differential for unexplained biliary duct dilation or obstruction in dogs. Dogs with disseminated histoplasmosis should be monitored for this potential complication.

Single Procedure Saline Lavage for Treatment of Inspissated Bile

Inspissated bile syndrome is a rare cause of cholestatic jaundice in infancy, occurring due to obstruction of the biliary ducts and gallbladder by biliary sludge. Traditional methods of treatment include surgical drainage or cholecystostomy drain placement. Both can be associated with complications and prolonged admission. We present 2 cases treated with a single percutaneous needle puncture of the gallbladder followed by saline lavage. Two neonates presented with cholestatic jaundice and sonographic evidence of biliary sludge and dilation of the common bile duct. Single sonographic-guided needle puncture of the gallbladder was followed by irrigation with saline. Clearing of the biliary sludge was confirmed by sonography and cholecystocholangiography. There was resolution of the cholestatic jaundice, with no complications or repeat procedures.

Hematospermia is rarely related to genitourinary cancer: lessons learned from 15 years of experience with 342 cases.

We investigated the prevalence of hematospermia among the 161,258 men with ≥18 years old, presenting to outpatient clinics with urologic complaints, between January 2003 and December 2017. We also recorded underlying causes of hematospermia to determine frequency of genitourinary cancer in 342 men who presented with hematospermia. Further evaluations such as urine/semen culture, Meares-Stamey four glass test, transrectal/scrotal ultrasound, pelvic magnetic resonance imaging (MRI), cystourethroscopy, and prostate biopsy were performed in the presence of additional symptoms and findings or recurrence of hematospermia after treatment of patients with monosymptomatic hematospermia. The prevalence of hematospermia was detected as 0.21% (342/161,258) among the urological patients. The mean age of the patients was 45.05 ± 14.04 years (range 18-85), and the median duration of hematospermia was 15 days (range 1-7200). In 306 (89.5%) of the patients, hematospermia was resolved after medical therapy for infections/inflammations, surgery for ductal obstruction and cysts, prostate and testicular cancer. However, 36 (10.5%) had persistent hematospermia. The most relevant etiologic cause of hematospermia was inflammation/infections in 169 patients (49.4%), and genitourinary cancers were detected in only 11 patients (3.2%) as prostate cancer in 8 and testicular cancer in 3. Hematospermia is seen frequently due to inflammatory or infectious causes, and is rarely associated with genitourinary cancer. However, genitourinary cancers should be kept in mind in the differential diagnosis of patients with recurrent/persistent hematospermia and associated symptoms, such as hematuria, lower urinary tract symptom, and scrotal pain/swelling.

Acute Pancreatitis – Etiology, Pathogenesis, Pathophysiology and The Current Trend in Its Management and Prevention

Acute pancreatitis is an episode of cellular injury and inflammation of the pancreas parenchyma triggered by autodigestion of pancreatic parenchyma by abnormally activated pancreatic enzymes, its manifestations ranges from mild, moderate-severe and severe pancreatitis. Most episode of acute pancreatitis resolved completely while some develop recurrent acute pancreatitis and in turn progressing to chronic pancreatitis and its sequelae. While many etiologies known may cause acute pancreatitis, current theories propose three mechanism that may be involved in the pathogenesis of acute pancreatitis i.e. duct obstruction, direct acinar injury and defective intracellular transport. Recommendations from current guidelines are very useful to treat acute pancreatitis, few groundbreaking changes from the previously dated guidelines on treating acute pancreatitis are also made,providing us dated evidence-based approach to treat acute pancreatitis. Judicious and aggressive treatment are needed to minimize the damaged area of involved pancreatic parenchyma. Holistic prevention is neededto minimize the incidence of acute pancreatitis, pushing down the numbers of recurrent acute pancreatitis and ultimately may decrease the incidence of chronic pancreatitis and its sequelae.

Impact of Physical Activity on Cognitive Functions: A New Field for Research and Management of Cystic Fibrosis.

Cystic Fibrosis (CF) is a genetic disease inherited by an autosomal recessive mechanism and characterized by a progressive and severe multi-organ failure. Mutations in Cystic Fibrosis Conductance Regulator (CFTR) protein cause duct obstructions from dense mucus secretions and chronic inflammation related to organ damage. The progression of the disease is characterized by a decline of lung function associated with metabolic disorders and malnutrition, musculoskeletal disorders and thoracic deformities, leading to a progressive decrement of the individual’s quality of life. The World Health Organization (WHO) qualifies Physical Activity (PA) as a structured activity produced by skeletal muscles’ movements that requires energy consumption. In the last decade, the number of studies on PA increased considerably, including those investigating the effects of exercise on cognitive and brain health and mental performance. PA is recommended in CF management guidelines, since it improves clinic outcomes, such as peripheral neuropathy, oxygen uptake peak, bone health, glycemic control and respiratory functions. Several studies regarding the positive effects of exercise in patients with Cystic Fibrosis were carried out, but the link between the effects of exercise and cognitive and brain health in CF remains unclear. Animal models showed that exercise might improve learning and memory through structural changes of brain architecture, and such a causal relationship can also be described in humans. Indeed, both morphological and environmental factors seem to be involved in exercise-induced neural plasticity. An increase of gray matter volume in specific areas is detectable as a consequence of regular training in humans. Neurobiological processes associated with brain function improvements include biochemical modifications, such as neuromodulator or neurohormone release, brain-derived neurotrophic factor (BDNF) production and synaptic activity changes. From a functional point of view, PA also seems to be an environmental factor enhancing cognitive abilities, such as executive functions, memory and processing speed. This review describes the current state of research regarding the impacts of physical activity and exercise on cognitive functions, introducing a possible novel field of research for optimizing the management of Cystic Fibrosis.

Treatment of acute pancreatitis with pancreatic duct decompression via ERCP: A case report series.

Acute pancreatitis is a common disorder in the gastrointestinal system, which is characterized by an increasing incidence and a high mortality. Currently, symptomatic treatment becomes the predominant option for the treatment of acute pancreatitis. To date, there is little knowledge on the treatment of acute pancreatitis through alleviation of pancreatic ductal hypertension and removal of pancreatic ductal obstruction. Endoscopic retrograde cholangiopancreatography (ERCP), an effective treatment for acute biliary pancreatitis, may alleviate the obstruction and edema in the common channel of the bile duct and pancreatic duct, to achieve the indirect treatment of acute pancreatitis, and may achieve the removal of intrapancreatic ductal obstruction and reduction in the intrapancreatic ductal pressure. Hereby, we report 3 cases with acute pancreatitis that were successfully treated by the pancreatic duct decompression via ERCP in one single center from China. Our data demonstrate that pancreatic duct decompression via ERCP is effective for the treatment of acute pancreatitis, which may shorten the course of acute pancreatitis through alleviating pain, shortening fasting duration and controlling the inflammatory reactions. It is recommended to use further prospective, randomized, controlled clinical trials to evaluate the efficacy and safety of pancreatic duct decompression via ERCP for acute pancreatitis.

Alcoholización percutánea de quiste hepático simple. Reporte de un caso y revisión de la literatura

With the advancement in complementary diagnostic methods, non-parasitic cystic liver disease has become a frequent reason for consultation in daily practice. Within the non-parasitic cystic disease of the liver, are the simple serous cysts, adult polycystic disease and pseudocysts. Simple cysts of the liver are intrahepatic cystic formations micro or macroscopic originating in conduits during embryonic development lose their communication with the biliary tree, either ductal obstruction or inflammatory hyperplastic ducts, thereby retaining liquid inside. We report the case of a patient with simple hepatic cyst which is the same as alcohol addiction takes minimally invasive definitive treatment. A literature review was performed highlighting treatment options for this disease.

Diagnostic accuracy of ultrasonography in adults with obstructive jaundice.

Aim of the studyTo determine the sensitivity and specificity of ultrasound for detecting the causes of obstructive jaundice.Materials and methodsEighty adult patients with clinical and biochemical features of obstructive jaundice were enrolled in this study. The causes, degrees and levels of ductal obstruction were evaluated sonographically via the transabdominal route. The ultrasonographic diagnoses were correlated with surgical findings and histopathological diagnoses.ResultsThe age range was 16 to 82 years, with a mean of 51.06 ± 14.95 years. The peak age group was the sixth decade with 23 (28.8%) patients. There were nearly twice as many females as males, with 28 (35%) males and 52 (65%) females, giving a male to female ratio of 1:1.9. On ultrasound, pancreatic carcinoma (28.0%) and choledocholithiasis (21.3%) were the most common malignant and benign causes of obstructive jaundice, respectively. Hepatocellular carcinoma (1.3%) was the least common etiology. There was a strong correlation between the definitive diagnosis and the sonographic level of obstruction. The overall sensitivity of ultrasound for detecting the cause of obstruction was 76.6%, while the specificity was 98%.ConclusionUltrasonography is a reliable imaging modality for diagnosing the cause and level of obstruction in surgical jaundice. The sensitivity is adequate to aid the early institution of surgical intervention, thereby preventing morbidity and mortality that may accompany late interventions in our setting.

Optimization and experiment of key components in pneumatic peanut pod conveyor

Research interest in pneumatic conveying technologies in processes such as peanut harvesting and shelling has grown rapidly in recent years. However, the use of pneumatic conveyors in this application suffers from high pod damage rates and duct obstruction. To address these issues, we analyzed the critical speed of pneumatic transport for conveying the peanut pods and measured the angle of friction and coefficient of restitution of peanut pods on a variety of material surfaces. Based on the results of these tests, optimizations and improvements were made to the separator bowl, air supply duct, and conveying duct. A pneumatic conveying experiment was then performed using peanut pods. In the factorial experiment, it was found that increases in fan speed increase the pod damage rate and transport efficiency, while increases in the thickness of the cushioning/anti-obstruction layer decrease the rate of pod damage and transport efficiency. Pod damage rates were significantly affected by fan speed, the thickness of the cushioning/obstruction prevention layer, and interaction between these factors, while transport efficiency was only significantly affected by fan speed. It is proved by the machine verification test, the optimal parameters for the pneumatic transport of Baisha peanut pods with a moisture content of 7.24% was a fan speed of 2700 r/min and a cushioning/anti-obstruction layer thickness of 6 mm. A pod damage rate of 5.19% and transport efficiency of 92.03% were achieved using these parameters, which are sufficient for meeting the requirements of industrial applications. Keywords: pneumatic transport, material properties, peanut pods, damage rate, transport efficiency DOI: 10.25165/j.ijabe.20201303.4609 Citation: Gao X M, Xie H X, Gu F W, Wei H, Liu M J, Yan J C, et al. Optimization and experiment of key components in pneumatic peanut pod conveyor. Int J Agric & Biol Eng, 2020; 13(3): 100–107.

Use of bacterial cellulose film for repair of bile duct injury in pigs.

The aim was to evaluate the use of bacterial cellulose film and bile duct autograft in repairing critical common bile duct injury in pigs. A prospective experimental analytical study was carried out on 20 Sus Domesticus, Piau suidae swine, divided into a control group (n = 10) and an experimental group (n = 10) divided into two subgroups: bacterial cellulose film E1 and bacterial cellulose film E2 to which bacterial cellulose film was randomly allocated. The control group underwent two complete critical common bile duct sections 10 mm apart, while the experimental group with a single critical common bile duct defect underwent a 10 mm section of the longitudinal shaft with edge resection. The defects in the control group were treated with end-to-end conventional anastomosis using polyglycolic 6-0 surgical thread and the experimental group with bacterial cellulose film by continuous suture using the same material. The animals were clinically evaluated throughout the experiment on days D150 (bacterial cellulose film E1), D225 (control group), and D330 (bacterial cellulose film E2) and by intraoperative ultrasound examination related to histopathological and biochemical findings. The intraoperative ultrasonography detected the changes resulting from the common bile duct anastomosis in the control group that produced a considerable incidence of ductal narrowing and obstruction to the biliary flow. In the bacterial cellulose film E2 group, there was an increase in inflammation intensity, granulomatous reaction, fibrosis, and vessels density, without producing bile duct dilation in the ultrasonography assessment. Biochemical analysis of liver enzymes yielded results in the normal range confirming preservation of liver function at the different post-surgery time points. Bacterial cellulose film, when used as a graft for bile duct repair, proved to be a biocompatible material that produced a complete healing process and biliary flow continuity.

Clinical aspects and surgical technique in Mirizzi syndrome: A systematic review

Mirizzi syndrome is described in the 1940s as follows: partial obstruction of the secondary common hepatic duct by gallstones, impacted on the cystic duct or gallbladder infundibulum, associated with the inflammatory response that involved the cystic duct and the common hepatic duct. As it is a rare and delicate condition, differential diagnosis is extremely important, in which the patient's clinical condition is verified through anamnesis and complementary exams, where immediately after the surgical intervention can be performed. This work aims to describe, through a literature review, the clinical aspects and the surgical technique in Mirizzi Syndrome. Were used as a database for research sites containing scientific articles available online such as Virtual Health Library (VHL), Scientific Electronic Library Online (Scielo) and PubMed. 154 articles were found through the descriptors, where after applying the inclusion and exclusion criteria 11 articles remained to write the work. According to the articles surveyed, it is clear that most of them do not report the syndrome as the main diagnosis, possibly because it is a pathology with signs and symptoms very close to other diseases of the bile duct, therefore leaving the syndrome sometimes described in the context of these other diseases. Finally, it concludes that even though the preoperative diagnosis is rare, it should be suspected in individuals undergoing biliary surgery.

Sarcomatoid carcinoma of the pancreas with rare long-term survival: a case report

BackgroundSarcomatoid carcinoma of the pancreas (SCP) tends to have similar or even worse prognosis than that of conventional pancreatic ductal adenocarcinoma. The clinical and pathological features of SCP remain poorly characterized owing to its rarity.Case presentationA 58-year-old man was admitted to our hospital with the chief complaints of upper abdominal pain and weight loss. Abdominal contrast computed tomography revealed a 5-cm low-density mass in the pancreatic body. Magnetic resonance cholangiopancreatography revealed an obstruction of the main pancreatic duct and a dilation of the distal main pancreatic duct. Based on the clinicoradiological findings, pancreatic body cancer was suspected, and the distal pancreatectomy was performed. A pathological examination revealed that the tumor was composed of an area of invasive ductal adenocarcinoma and an area of sarcomatous spindle-shaped cells; the latter component predominated. The spindle cells were immunohistochemically positive for both cytokeratin and vimentin, and thus, a pathological diagnosis of SCP was made. In addition, immunohistochemical analysis suggested the sarcomatous component might be derived from the adenocarcinoma component via the process of epithelial-mesenchymal transition. After the operation, the patient received 6 months of chemotherapy with gemcitabine. At 10 years after the operation, the patient is alive with no recurrence.ConclusionsThe current case study presented a SCP patient with long-term survival after the operation. It was worth noting that the sarcomatous component of the tumor pathologically showed lower MIB-1 labeling index compared with those in previously reported SCP cases, which might account for the long-term survival of the patient.

Modern view of biliary atresia in children

Atresia of the biliary tract, or biliary atresia (BA), is a destructive, inflammatory disease in which progressive biliary tree fibrosis in an infant leads to obstruction of the bile ducts and, as a result, to cirrhosis of the liver. If untreated, progressive cirrhosis leads to death by 2 years. Biliary atresia can be divided into 3 types, each of which depends on the level closest to biliary obstruction. Type I (obstruction of the common bile duct), type II (patency of the bile ducts to the level of the common hepatic duct), type III (obstruction at the level of the gates of the liver). It is very important to distinguish between types of BA and conduct differential diagnosis with other cholestatic diseases. There are nonsyndromic, syndromic, and BA, combined with other malformations. In diagnostics, in addition to clinical manifestations and specific changes in blood biochemical parameters characterizing cholestasis, an ultrasound examination of the abdominal cavity organs, gepatobiliscintigraphy, magnetic resonance cholecystopancreatocholangiography, according to indications, a puncture biopsy of the liver and histological examination are performed. The main method of treatment is hepatoportoenterostomy according to Kasai, which must be performed no later than 3 months, and with liver cirrhosis and hepatic insufficiency, liver transplantation. Additional methods of treatment include the use of ursodeoxycholic acid, fat-soluble vitamins.

Acutely Inflamed Mamilla - Mastitis and Abscess

Mastitis is an inflammation of breast parenchyma, predominantly occurring in the breastfeeding period, with or without accompanying infection and appears as lactational or puerperal and non-lactational as is associated with duct ectasia. Breast abscess is a focal accumulation of purulent substances within the breast parenchyma emerging as a complication of mastitis and is common in lactating women. Comprehensive incidence of mastitis is around 33% whereas breast abscess arises in approximately 3% to 11% of subjects with mastitis. An estimated two fifths (40%) of breast abscess or certain breast infections are poly-microbial and specific aerobes such as Staphylococcus, Streptococcus, Enterobacteriaceae, Corynebacterium, Escherichia coli and Pseudomonas along with anaerobes as with Pepto-streptococcus, Propionibacterium, Bacteroides, Lactobacillus, Eubacterium, Clostridium, Fusobacterium and Veillonella can engender the disease. Subjects with mastitis enunciate flu-like symptoms with malaise, myalgia, fever, mammary pain, decline in milk egress, local warmth, tenderness, firmness and swelling of breast region and localized erythema. Breast abscess usually delineates mammary pain and/or a breast lump. Lactational breast abscess morphologically recapitulates an acute inflammation whereas non-lactational breast abscess is commonly sub-areolar and appears as a fistula of lacteriferous ducts, eventually emerging as chronically draining sinuses and breast abscess adjacent to the areola. Squamous metaplasia of lacteriferous duct epithelium, duct obstruction, and sub-areolar ductal dilatation or duct ectasia can ensue.

Combined extracorporeal shock wave lithotripsy and endoscopic treatment for pain in chronic pancreatitis (SCHOKE trial): study protocol for a randomized, sham-controlled trial

BackgroundPain is the primary symptom of chronic pancreatitis (CP) and remains a considerable therapeutic challenge. In patients with obstruction of the pancreatic duct, including stones and strictures, endoscopic treatment with or without preceding extracorporeal shock wave lithotripsy (ESWL) has been used for pancreatic duct decompression. The rationale for these procedures is based on the assumption that obstruction of the pancreatic duct leads to ductal hypertension and pain. However, clinical pain symptoms correlate poorly with pancreatic duct morphology, and the evidence for pancreatic duct decompression as an effective treatment for pain is based on case series and comparison between different procedures. No randomized, prospective, sham-controlled trials are currently available. The SCHOKE (Extracorporeal Shock Wave Lithotripsy and Endotherapy for Pain in Chronic Pancreatitis) trial is a randomized, sham-controlled trial designed to determine if pancreatic duct decompression is an effective treatment for pain in patients with CP.MethodsThe SCHOKE trial is a randomized, single-blind, parallel-group, sham-controlled trial designed to evaluate the effect of combined ESWL and endoscopic treatment for pain in patients with CP. In total, 106 adult patients with painful CP and pancreatic duct obstruction will be randomized to combined ESWL and subsequent endoscopic treatment or corresponding sham procedures. The primary outcome is pain relief during the 3-month postrandomization period as documented in a pain diary. Secondary outcomes include quality of life and functional scores, patient global impression of change, change in use of analgesics, frequency of hospitalization, and complications. Standard follow-up is at 3 and 6 months after randomization. In an experimental substudy, quantitative sensory testing obtained before and after intervention will be used to obtain information on central pain processing and to develop models for prediction of treatment outcome.DiscussionThe SCHOKE trial investigates if pancreatic duct decompression, obtained by combined ESWL and endoscopic treatment, is effective for pain treatment in patients with CP.Trial registrationClinicalTrials.gov, NCT03966781. Registered on May 25, 2019.Protocol date and version identifier: March 1, 2020; version 3.0.Sponsor: Rupjyoti Talukdar, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India.