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Biomedical subjects

M Cremer

Publications and source records attributed to M Cremer.

At least 217 records · Page 12Linked to original sources
PubMedDate not supplied

A rare cause of biliary pain in Belgium.

Ascaris lumbricoides is the most frequent human helminthic parasite. Usually human ascariasis is poorly symptomatic but complications can arise due to worm migration. Erratic worm migration into the biliary tree is a rare but threatening condition regarding the associated complications: cholecystitis, pancreatitis, obstruction of bile ducts, liver abcesses and recurrent pyogenic cholangitis. We describe a case of a young belgian women suffering from recurrent biliary colics over a period of eight months with repeated normal ultrasound findings. ERCP proved being the only effective diagnostic procedure for a living biliary worm, which was successfully removed with a balloon catheter.

Adult↗
PubMedDate not supplied

Endoscopic palliation of malignant dysphagia.

In patients with obstructive tumors of the esophagus and who cannot undergo curative surgery, endoscopic palliative methods can provide a quick relief of dysphagia with subsequent improvement of nutritional status. The technical success rate is as high as 95% for intubation and 100% for laser therapy. Both methods have their specific indications. Intubation is often able to provide quick and definitive palliation while laser therapy requires several sessions and relapses of obstruction are frequent. On the other hand, intubation carries a high risk of perforation (8.7%), and laser appears to be safer (1.7% perforation). Both methods can be combined in many instances, and their association with afterloading or external beam radiation therapy can be beneficial. Even if the overall survival rate is only 6 to 7 months, the improvement of the quality of life is the priority goal of these methods.

Deglutition Disorders↗
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Endoscopic stenting for biliary strictures.

A consensus is growing among units that have an experience in both endoscopic and percutaneous stenting techniques that the endoscopic approach of malignant biliary strictures is more comfortable for the patient and provides less complications. This article describes endoscopic biliary drainage in different malignant stenosis of the bile ducts and delineates the respective indications of percutaneous and endoscopic techniques together with the possible combination of these two methods in selected cases. It also tackles the question of the medical surgical approach of the patients, which might, thanks to a better selection, reduce the morbidity and mortality associated with surgery. The indications of biliary stenting in benign strictures, namely post operative or chronic pancreatitis associated biliary stenoses, are also discussed. Recently, new materials became available for endoscopic and percutaneous biliary drainage, and particularly metallic self expanding stents which might provide a better palliation among these patients. If these stents fulfill their promise on longer follow-up, they may replace the conventional stenting devices.

Biliary Tract Neoplasms↗
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[Enteroscopy: methods and results].

Recent advances in the instrumentation and techniques of enteroscopy now permit examination of the small bowel. This report is on the use of a prototypic small bowel enteroscopy to investigate patients with gastrointestinal bleeding of obscure origin. We used the sonde-type enteroscope (Olympus Corp.) that migrates distally responding to peristaltic activity. This instrument has neither tip deflection controls nor interventional capability. Small bowel enteroscopy was performed in 17 patients. Arteriovenous malformations were visualized in 5 patients but three of them suffered from Rendu-Osler disease. Small bowel enteroscopy can be useful in the evaluation of patients with gastrointestinal bleeding of obscure origin. However, patients must be well selected on basis of negative routine examinations because this method is time-consuming.

Adult↗
PubMedDate not supplied

Non-surgical management of achalasia.

Pneumatic dilatation of the cardia is an effective procedure to treat patients suffering from achalasia. Eighty percent of these patients can be expected to have excellent or good results for 6 years after the first dilatation. A repeat dilatation should be performed as soon as the patient has recurrent symptoms, usually every 2 years. Calcium channel blockers (nifedipine and verapamil) or nitrates (isosorbide dinitrate) decrease LES pressure but do little to the clinical symptomatology of patients with achalasia; however such drug therapy may be tried as an adjunct in patients who remain symptomatic after pneumatic dilatations or myotomy. Pneumatic dilatation and surgical myotomy both reduce LES pressure; with pneumatic dilatation, enough residual LES pressure is retained to prevent gastroesophageal reflux. Indeed, reflux esophagitis seems to occur more often after surgery than after forceful dilatations. We think that pneumatic dilatation should be performed as the primary therapy and surgery reserved for the failures of this procedure.

Adult↗
PubMedDate not supplied

Treatment of peptic ulcer severe bleeding.

The success of a defined management policy op peptic ulcer haemorrhage which incorporates endoscopic therapeutic intervention depends on the early identification of a high risk group of patients and a high risk group of ulcers. The high risk group of patients consists of those likely to experience further bleeding on the basis of clinical prognostic indicators: shock and severe anaemia on admission and the pattern of bleeding; or tolerate rebleeding and emergency surgery poorly: patients over 60 years and those with associated disease. UGI endoscopy should be performed early (within 6-12 hours) in this group in order to identify the bleeding point and provide prognostic information regarding the risk of further haemorrhage. Peptic ulcers with major stigmata of recent bleeding (spurting or non-bleeding visible vessel) have high risk of rebleeding, the risk is even greater when major stigmata of recent haemorrhage (SRH) are associated with shock on admission. Patients with such ulcers should be monitored intensively and receive endoscopic haemostatic treatment in order to terminate active haemorrhage or prevent rebleeding thereby avoiding the need for emergency surgery with its attendant morbidity and mortality. Patients with ulcers with minor or no SRH have a very low risk of rebleeding and don't require intensive monitoring or endoscopic treatment and can be discharged from hospital early. Ulcers which cannot be completely characterized have an intermediate risk of rebleeding and should be managed as high risk lesions. Secondary to the anatomy of the visible vessel any haemostatic endoscopic treatment should be applied around, but avoiding, the sentinel clot. Well-designed randomized controlled trials of endoscopic haemostatic treatment of peptic ulcer haemorrhage in which stratification of risk was based on the SRH, have demonstrated for non-bleeding vessel a significant reduction in rebleeding and in emergency surgery, for spurting bleeding benefit was found only for the rebleeding risk. No advantage was demonstrated in each group of patients in term of mortality. Such studies also demonstrate the superiority of the Nd:YAG laser over the Argon laser. Perforation is a rare complication of Nd:YAG laser photocoagulation (less than 1%). Precipitation or aggravation of arterial haemorrhage during treatment of a visible vessel, as a result of a direct hit, is a more frequent complication (0-29%). Further laser treatment is successful in terminating 75% of these induced bleeds, the remainder requiring surgery. Preinjection of the ulcer with adrenaline does not appear to prevent this complication.(ABSTRACT TRUNCATED AT 400 WORDS)

Gastroscopy↗
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Clinical significance of pancreas divisum.

Pancreas divisum (PD), a congenital anatomic variant consisting of a separate pancreatic ductal system, is diagnosed in nearly 10% of patients for whom a successful pancreatogram was obtained. The relationship between PD and pancreatic disease is discussed since 1976. Some authors, reporting a higher incidence of pancreatitis in patients having two separate pancreatic ducts, proposed the concept of relative outflow obstruction of pancreatic juice through the accessory papilla. Based on the literature data and on our own experience, this review asserts that there is no definite evidence for PD being associated with a significantly risk of idiopathic pancreatitis. Discrepancies between epidemiological series could be explained by selection biases leading to an apparent association of PD and pancreatitis. An objective assessment of accessory papilla stenosis in patients with PD is not clearly available to give consistent results. Although controversies persist with regard to the actual abnormality of PD and the presence of stenosis into the accessory papilla, several endoscopic and/or surgical procedures have been proposed in an attempt to correct what is thought to be a stenosis of the orifice of the dorsal duct. More than 300 patients have been treated until now with variable and unpredictable results, these treatments are not devoid of complications. We conclude that PD should be considered as a frequent coincidental anatomic variant having no clinical significance in the great majority of patients and not requiring systematic further therapy.

Ampulla of Vater↗
PubMedDate not supplied

Operative colonoscopic endoscopy.

There are several conditions where operative colonoscopy is useful. Acute colonic pseudo-obstruction or Ogilvie's syndrome is characterized by a acute distension of the colon. Although medical management may be sufficient in many cases, endoscopic decompression must be performed when colonic distension is greater than 12 cm. Insertion of decompression tube to avoid rapid recurrence seems to be adequate. In case of massive lower intestinal hemorrhage, colonoscopy seems to be more accurate than mesenteric angiography. Such endoscopic examination requires an experienced endoscopist. Colonoscopic polypectomy has become the standard method for removal of colonic polyps. Factors influencing the rate of complications have been studied. While the number of complications was very low, we have observed that all the major hemorrhages were immediate when the blended current was used, but delayed when the pure coagulation current was applied. Endoscopic laser photocavitation is a valuable palliative method treating rectal adenocarcinoma in well selected patients. Indeed, if the patients survive sufficiently long after initial therapy, it becomes increasingly difficult to achieve persistent palliation with laser therapy.

Adenocarcinoma↗
PubMedDate not supplied

[Primary sclerosing cholangitis: contribution of retrograde cholangiography in follow-up: apropos of 15 case reports].

From 1975 to 1989, primary sclerosing cholangitis (PSC) was diagnosed in 15 patients especially based on cholangiographic features associated with clinical, biological and histological findings. 93 p. cent of patients had altered liver enzymes at the diagnosis time but only 26% was asymptomatic. 33 p. cent had a concomittant inflammatory bowel disease. Retrograde cholangiography showed injuries of the intrahepatic ducts in 93 p. cent; the more frequently observed lesions were short and multifocal strictures, associated with irregularities of the biliary wall or decreased arborization of intrahepatic bile ducts, but without marked dilatation. Mean follow-up was 44 months (3 to 120). Actuarial survival was 48 p. cent at 5 years. In 4 patients, because of poor clinical and biological (serum bilirubin greater than or equal to 4 mg/dl) evolution, a second retrograde cholangiography was performed showing in all cases apparition of marked ductal dilatation in extra-hepatic (one case) or in intra-hepatic bile ducts (three cases). We diagnosed one benign extra-hepatic stricture, two cholangiocarcinoma and one biliary cirrhosis complicating PSC. We concluded that retrograde cholangiography is necessary if jaundice appears to diagnose every complications of PSC. Apparition of marked ductal dilatation should be the witness of pejorative evolution, especially apparition of cholangiocarcinoma that must be excluded.

Adult↗
PubMedDate not supplied

[Use of diuretics in the treatment of ascites in patients with cirrhosis].

The cirrhotic patient with ascites has an increased tubular reabsorption of sodium. Diuretic therapy allows an urinary loss of sodium. The strongest diuretics which inhibit sodium reabsorption in the ascending limb of the loop of Henle (like furosemide) are not the most effective in cirrhotic patients; indeed the increased load of sodium arriving in the distal part of the tubule is reabsorbed because of hyperaldosteronism. Potassium-sparing diuretics, like spironolactone, which act beyond the sites of reabsorption of most of the filtered sodium, are mostly effective when combined with other diuretics which impair sodium reabsorption more proximally. We propose to treat ascites by: 1. Sodium restriction (maximum: 60 mmol per day); 2. Spironolactone 100 to 500 mg per day, combined with furosemide 40 to 200 mg per day if spironolactone does not induce a natriuretic effect.

Ascites↗
PubMedDate not supplied

[Non-invasive methods for assessing the small intestines].

Non-invasive methods investigating small bowel functions are critically reviewed. For intestinal absorption, we discuss the value of fecal fat determination, D-xylose testing and breath tests. Intestinal bacterial overgrowth may be assessed by breath hydrogen test or 14C-D-Xylose breath test. Small intestinal transit time can be measured by a scintigraphy method or by a breath hydrogen technique. Intestinal clearance of alpha-1 antitrypsin is now the method of choice for the detection of protein-losing enteropathy. Intestinal permeability can be assessed by 51Cr-EDTA/14C-mannitol ratio or PEG 900 method.

Breath Tests↗