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Biomedical subjects

B Kohler

Publications and source records attributed to B Kohler.

At least 55 records · Page 3Linked to original sources
PubMed1994

[Benign bile duct stenosis--conservative management as long as possible?].

The clinical course of 37 patients (15 female, 22 male) treated endoscopically for benign biliary stenosis was analyzed retrospectively. Patients with chronic pancreatitis (n = 20) were compared to those (n = 17) with biliary stenosis due to other reasons, postoperative strictures in most cases. Each patient received at least one 10- or 11.5-French endoprosthesis. The liver enzyme and serum bilirubin levels returned to normal or slightly elevated levels. The average time until exchange or extraction of the prosthesis was 11.4 (range 2 to 33) months in patients with chronic pancreatitis and 5.1 (0.5 to 21) months in patients with postoperative strictures. The therapy was completed by extraction of prosthesis in six patients with chronic pancreatitis (30%) and in 14 patients with stenosis due other reasons (82.3%). None of the patients died of complications related to endoscopic therapy.

Adult↗
PubMed1994

[Acute pancreatitis due to the rupture of an echinococcal cyst into the bile duct system].

A 47-year-old woman with stones in the gall-bladder suddenly developed severe upper abdominal pain. Cholesterol concentration was elevated, as were amylase (555 U/l) and lipase (408 U/l) concentrations, suggesting biliary pancreatitis. Endoscopic retrograde cholangiography demonstrated a cyst, about 10 cm in diameter, in the left lobe of the liver, connected to the biliary tract system. Ultrasonography and computed tomography additionally showed a smaller cyst in the right lobe. Infection with Echinococcus granulosus was proven microbiologically on bile (demonstration of hooklets and protoscolices) as well as serologically. Transpapillary cholangioscopy demonstrated daughter cysts within the echinococcal cyst. The main cyst was rinsed with 20% NaCl for 10 days via a nasocystic catheter. In addition, mebendazole (three times daily 1000 mg) was administered for 13 months. The signs if inflammation receded and the cyst shrank to a small residual volume. Surgical intervention became unnecessary.

Acute Disease↗
PubMed1994

Fluoroscopically guided laser lithotripsy of a pancreatic duct stone.

A 54-year-old man with early stage chronic pancreatitis and an impacted ductal stone in the pancreatic head complicated by a 2 cm abscess was treated with pulsed dye laser lithotripsy using an automatic stone tissue differentiation system under fluoroscopic control. This system automatically switches off the laser on contact with tissue. The 0.25 mm quartz fiber introduced into the pancreatic duct via a 5 French teflon catheter delivered 165 out of 1000 pulses at contact with the stone (100 mJ, 10 Hz). Partial stone disintegration was achieved making mechanical stone removal possible which initially failed. No major side-effect occurred. This new laser with a stone detection system seems to render fluoroscopically guided laser lithotripsy in the pancreatic duct safer thus warranting further clinical trials.

Calculi↗
PubMed1994

Attendance at accident and emergency departments: unnecessary or inappropriate?

The proportion of attenders at accident and emergency (A&E) departments who present 'inappropriately' with conditions which could be managed in general practice has been estimated at between 6.7 per cent and 64-89 per cent. These estimates have been based on subjective assessments by clinicians, or on an objective classification developed by the Nuffield Provincial Hospitals Trust (NPHT). This study sought to validate this classification, and to develop and validate other objective systems of classifying A&E attenders. Two novel methods were devised, one based on the ICD-9 diagnosis and one primarily on processes of care. All three techniques were validated against the pooled opinions of a sample of general practitioners (GPs). The existing NPHT classification was found to be very unreliable. The new diagnostic method was more specific but had poor sensitivity, whereas the technique based on processes of care agreed remarkably well with the sample of GPs. This method was applied retrospectively to random samples of 8877 adult self-referrals to 16 English A&E departments, and yielded an estimate that 23 per cent could have been treated in general practice. This approach provides a simple and valid retrospective method for identifying patients who were suitable for care in general practice. The method may be used to identify groups of patients who frequently attend inappropriately, to identify areas in which primary care needs are not being effectively met in general practice, and to form a basis for planning and auditing strategies to meet those needs in a more appropriate setting.

Adult↗
PubMed1994

Cost effectiveness of adjuvant bile salt treatment in extracorporeal shock wave lithotripsy for the treatment of gall bladder stones.

The relative cost effectiveness of adjuvant urso and chenodeoxycholic acid treatment in extracorporeal shockwave lithotripsy (ESWL) has been assessed as part of a pragmatic randomised controlled trial of ESWL as a treatment of gall bladder stones. Of the first patients with gall stone volume < 4 cm3 randomised to ESWL in the main trial, 24 were randomised to have ESWL alone and 26 to have adjuvant bile acid treatment, one of whom died before the end of the 12 month follow up period. At 12 months after treatment, differences in gall stone clearance between ESWL alone (3/24 (13%) clear, 5 (21%) referred for surgery) and ESWL and bile acids (6/25 (24%) clear, 2 (8%) referred for surgery) were not significant (p = 0.36, log rank test). Patients in both groups had substantial and significant health gains (according to biliary pain frequency and severity, Nottingham Health Profile scores, visual analogue scale symptom scores, and complications) but there were no significant differences between the groups. Improvements in both groups usually occurred within a few weeks of treatment and were unrelated to gall stone clearance. Costs were greater in the bile salt group (95% confidence intervals for estimated cost difference: 90 pounds to 630 pounds). If the purpose of treatment is symptom relief rather than gall stone clearance then adjuvant bile salt treatment seems to be unnecessary.

Adult↗
PubMed1994

[Acute segmental hemorrhagic penicillin-associated colitis in a 32-year-old patient].

We report on a 32-year old patient who developed acute abdominal cramps and bloody diarrhea two days after taking phenoxymethyl penicillin. After excluding other causes, we diagnosed an acute segmental hemorrhagic penicillin associated colitis. In this case report we discuss the literature on this diagnosis and present the etiology, course, prognosis, and differential diagnosis of this entity.

Adult↗
PubMed1994

Does Doppler ultrasound improve the prognosis of acute ulcer bleeding?

The visible vessel in the floor of the ulcer seen on endoscopy is one of the most important prognostic factors of ulcer bleeding. With the ultimate aim of improving the purely visual interpretation of the base of the ulcer, we investigated the utility of an innovative pulsed endoscopic Doppler procedure in 140 patients with acute ulcer bleeding. Agreement between the endoscopic appearance and the Doppler ultrasonographic findings was observed in only 59% of the ulcers. In all Doppler-positive ulcers, injection therapy was performed irrespective of the endoscopic appearance of the ulcer. This was repeated if the ulcer was still Doppler-positive on repeat examination. With this strategy, only 9% recurrent hemorrhages were seen, and there was no hemorrhage-associated mortality. Among the Doppler-negative lesions, which received only medical treatment, no rebleeding was observed. On the basis of these results, it would appear that a Doppler ultrasound oriented classification of ulcer bleeding is superior to the Forrest classification based on a purely visual interpretation. The endoscopic Doppler verifies the visual impression of the ulcer, identifies the indication for operative endoscopy, and can monitor the effectiveness of the latter.

Acute Disease↗
PubMed1994

[Mucinous cystadenomas and cystadenocarcinomas of the pancreas--the pancreaticoscopy as a new device for endoscopic and histological diagnosis].

Recent advances in diagnostic imaging procedures offer the opportunity for detection of rare cystic neoplasms of the pancreas. Cystadenomas of the pancreas have been reported to represent 10% of cystic pancreatic lesions. Serous microcystic cystadenoma, megacystic mucinous and duct-ectatic mucinous cystadenoma were distinguished. While the serous cystadenoma is benign, in general the megacystic and the duct-ectatic mucinous cystadenoma have a significant malignant potential. With pancreatoscopy, a rather new endoscopic technique, five cases of mucinous megacystic cystadenoma were diagnosed preoperatively by macroscopic and microscopic means. In one case, development of malignant neoplasm was diagnosed, one patient did not undergo surgery because of her age. Three patients were operated (total pancreatectomy in one case, duodeno-hemipancreatectomy in two cases) and are without any further signs of recurrence and free of symptoms in a one year to four year clinical follow-up.

Adult↗
PubMed1993

Endoscopic injection therapy of Forrest II and III gastroduodenal ulcers guided by endoscopic Doppler ultrasound.

Endoscopic Doppler ultrasound enables the reliable identification of vessels in the base of gastroduodenal ulcers. In a prospective study including 114 patients with acute ulcer bleeding, pulsed Doppler ultrasound was able to demonstrate superficial blood vessels in the ulcer base in 62% of 106 cases where complete Doppler assessment was possible (93%). Agreement between the endoscopic pattern of visible vessels and the Doppler ultrasound findings was attained in only 52% of the cases. Doppler positive ulcers (n = 66) were treated with injection therapy (if necessary, repeated), irrespective of their Forrest classification. Using such an approach, the rebleeding rate in this group decreased to less than 8% and none of the patients died of causes related to the hemorrhage. All Doppler negative ulcers (n = 40) healed without complications or the need for endoscopic treatment; among these were 11 cases with Forrest IIa and b. We conclude that endoscopic Doppler appears to be a valuable diagnostic procedure in the assessment of bleeding ulcers, thus modifying the Forrest classification. Our concept is that Doppler positive ulcers require local endoscopic treatment, whereas Doppler negative ulcers can be treated conservatively.

Adolescent↗
PubMed1993

Direct dissolution of gallstones with methyl tert-butyl ether by endoscopic cannulation of the gallbladder.

Methyl tert-butyl ether (MTBE) rapidly and effectively dissolves cholesterol gallbladder stones. Due to the invasive nature of transhepatic catheterization, we studied the safety and efficacy of MTBE stone dissolution, delivered by endoscopic, retrograde cannulation of the gallbladder. Extracorporeal shock-wave lithotripsy (ESWL) was employed in patients with multiple stones, to increase contact surface area and facilitate dissolution. We successfully cannulated the gallbladder in 13/17 patients (76.5%) attempted, with no associated complications. After cannulation, MTBE lysis was then conducted on all patients, and 10/13 patients (77%) cannulated were either stone-free at completion, or had only residual gallbladder sludge. Predissolution ESWL successfully fragmented stones in 6/7 patients (86%) in which it was attempted. Both ESWL and MTBE were well tolerated by all patients. Endoscopic retrograde cannulation of the gallbladder and MTBE dissolution is a promising alternative for the treatment of gallbladder stones in patients who will not receive surgery.

Aged↗
PubMed1992

Randomised controlled trial of cost-effectiveness of lithotripsy and open cholecystectomy as treatments for gallbladder stones.

Inpatient extracorporeal shockwave lithotripsy for treatment of gallbladder stones has not previously been compared with open cholecystectomy in terms of cost-effectiveness. In a randomised controlled trial, 163 patients, stratified by gallstone bulk (over 4 cm3 or not), were randomised to lithotripsy or cholecystectomy (38 large-bulk and 27 small-bulk cholecystectomy; 37 large-bulk and 61 small-bulk lithotripsy) and followed up for 1 year. Both treatments gave significant health gains in terms of a reduction in episodes of biliary pain, improved perceived health status, and symptom relief, but few differences between treatments were found. There was some evidence that biliary-pain episodes were less severe after cholecystectomy. Cholecystectomy patients also had greater improvements in mean health gain for three related symptoms: vomiting, feeling sick, and fatty-food upset. However, there were no differences between groups in perceived health status. Among lithotripsy patients, health gain was not related to stone clearance. Lithotripsy was more expensive than cholecystectomy, principally because of the costs of the inpatient stay and adjuvant bile-salt therapy. Conventional lithotripsy appears at least as cost-effective as cholecystectomy for patients with small-bulk stones but less cost-effective for those with large-bulk stones. To some extent treatment choice can be guided by patient preference.

Adult↗
PubMed1992

[Ménétrier's disease--a rare cause of a protein deficiency syndrome].

Hypoproteinaemia (total proteins 5.2 g/dl) and hypoalbuminaemia (2.7 g/dl) were demonstrated in a 44-year-old woman with leg oedema during the previous four months and 10-kg weight gain during the previous year. A protein-losing enteropathy was diagnosed, all other causes having been excluded. Gastroscopy revealed giant hypertrophic gastritis. A biopsy showed foveolar hyperplasia with some inflammatory infiltrates, typical of Ménétrier's disease. Endosonography excluded any additional infiltrative process of the bowel wall. Long-term treatment with ranitidine, 150 g twice daily, achieved normalization of total protein and albumin concentrations. But the macroscopic changes in the gastric wall were still recognizable on repeat gastroscopy. As there is a danger of malignant degeneration gastroscopy and, if indicated, endosonography should be repeated annually.

Adult↗