Biomedical subjects
Publications and source records attributed to D M Jensen.
A 55-year-old woman suffered acute hepatic necorsis following ingestion of Amanita virosa mushrooms. Successful treatment included the use of thioctic acid. A discussion of Amanita poisoning an the therapeutic modalities available is presented.
Successful therapy for liver diseases, including autoimmune hepatitis, primary biliary cirrhosis, and hepatitis C, has been associated with a reduction in hepatic fibrosis. Recently, a study of needle liver biopsy specimens documented resolution of cirrhosis in a small group of patients with autoimmune hepatitis who responded to corticosteroid therapy. We describe a woman with autoimmune hepatitis who had cirrhosis on a wedge biopsy of the liver in 1985 and who attained a biochemical response with immunosuppressive therapy. A repeat wedge liver biopsy performed 14 years later was normal, providing unequivocal evidence that cirrhosis can reverse completely in autoimmune hepatitis.
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Endoscopic ultrasound is a new technology that improves the local staging of esophageal, gastric, and rectal carcinomas. In addition, EUS may provide useful information which will affect management in individual patients with subepithelial masses (e.g., varices, leiomyomas) and pancreatic diseases. Other imaging studies such as transcutaneous ultrasonography and CT are still necessary to detect distant metastatic disease. At present, EUS may be best reserved for use by individuals who have sufficient patient materials to provide broad experience with the technique. Physicians at centers where large numbers of patients with gastrointestinal cancer are evaluated may find this technology most useful. Even in patients with malignancy, however, studies are needed to show that the improved local staging by EUS will translate into changes in patient management and improved outcome.
Large caliber plastic stents (10 to 11.5 French) have become widely accepted as an alternative to surgery in the treatment of many malignant and benign lesions of the biliary tract. Procedure-related early complications occur at an acceptable rate (8 to 10%) and procedure-related mortality is approximately 2%. Late clogging occurs at a mean of 4 to 6 months. This results in the need to change a clogged stent in 20 to 35% of surviving patients with malignant disease. In benign or malignant disease, when long-term stenting is desired, it is generally recommended to prophylactically replace the stent every 4 to 6 months to avoid clogging. While several mechanisms of clogging have been elucidated, research studies have failed to lead to a clinically available improvement in duration of patency. The role of expandable metal stents in the treatment of malignant and benign biliary strictures has not been established. Despite their large internal diameter, they may be associated with late problems related to stent clogging from tumor ingrowth or overgrowth. Technical difficulties and expense, as well as lack of data from prospective randomized trials, limit current recommendation for their use at this time.
Monopolar hot biopsy forceps were developed for simultaneous tissue biopsy and electrocoagulation. Many endoscopists used these forceps for coagulation of diminutive polyps of the colon. The rationale for diminutive polyp eradication is to destroy neoplastic tissue and possibly prevent colon cancer. However, convincing data to document a reduction in the incidence of colorectal cancer or even complete obliteration of all treated diminutive polyps with hot biopsy forceps are lacking. Complications of hot biopsy include hemorrhage, perforation, and post-coagulation syndrome. Tissue injury is deeper with monopolar hot biopsy forceps than bipolar forceps. The right colon is particularly susceptible to transmural injury and perforation. For small polyp obliteration, comparative studies of hot biopsy (monopolar and bipolar) with other techniques such as cold biopsy combined with thermal probes, large cup cold biopsy removal, and snare electrocoagulation are warranted. The necessity to biopsy typical appearing angiomata does not seem warranted on a routine clinical basis. The expected obliteration rates of small angiomata or rates of controlling lower gastrointestinal bleeding from colon angiomata after monopolar hot biopsy electrocoagulation have not been well documented. Heater probe or bipolar electrocoagulation have been safely and effectively applied to bleeding colon angiomata. These newer coagulation probes are recommended as an alternative to hot biopsy forceps for treatment of bleeding colonic angiomata.
SO manometry appears to be helpful in defining a group of patients with biliary pain or idiopathic recurrent pancreatitis who may benefit from endoscopic or surgical treatment. It is a procedure that requires considerable time and endoscopic expertise along with knowledge of the manometric interpretation of sphincter of Oddi dysfunction. The diagnostic accuracy of SO manometry and criteria for basing therapeutic decisions on manometric findings need further study and verification.
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