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Biomedical subjects

R H Schapiro

Publications and source records attributed to R H Schapiro.

35 records · Page 2Linked to original sources
PubMed1984

Epstein-Barr viral hepatitis: an unusual case and review of the literature.

We report a patient with icteric hepatitis and abdominal pain caused by Epstein-Barr virus in the absence of other common features of infectious mononucleosis. The peak alanine aminotransferase was 289 IU/I. Hemolytic anemia and urinary retention complicated the patient's course. Patients with infectious mononucleosis commonly have hepatic involvement but isolated symptomatic hepatitis is unusual. Although rare cases of liver failure have been reported, there is no evidence that Epstein Barr virus causes chronic liver disease. The clinical and histological features of Epstein Barr virus-induced hepatitis are reviewed.

Abdomen↗
PubMed1983

Abnormalities of the pancreatic and biliary ducts in adult patients with choledochal cysts.

A choledochal cyst in the adult patient is not just an aneurysmal dilatation of the common bile duct, but it is the most obvious manifestation of a more widespread pancreaticobiliary ductal dysplasia. Most patients have abnormalities of the pancreatic ducts and, frequently, multiple areas of dilatation involving the intrahepatic bile ducts. Of our nine patients, six had pancreatograms, five of which were distinctly abnormal. Two of the five had recurrent pancreatitis. Six patients were found to have marked stenosis of the outflow tract from the cyst. Because the mucosa lining the choledochal cyst was chronically ulcerated, anastomoses to the cyst formed strictures in seven (64%) of 11 patients, and the long-term risk of carcinoma arising in the cyst was increased. The preferred therapy was excision of the cyst with Roux-en-Y hepaticojejunostomy.

Adolescent↗
PubMed1983

The cause and treatment of pancreatitis associated with pancreas divisum.

Recurrent pancreatitis is more prevalent in the 4% of people with pancreas divisum (nonfused dorsal and ventral ducts), and it has been proposed that the pancreatitis is caused by stenosis at the orifice of the dorsal duct. We have treated 40 patients with pancreas divisum and proven or probable pancreatitis. The diagnoses were made by endoscopic pancreatography showing a foreshortened (less than 6 cm) ventral duct (Wirsung) and confirmed by postoperative pancreatograms showing the separate main duct (Santorini) emptying via the accessory papilla. Of these, 32 patients (25 men, 7 women, median age 30) had recurrent acute pancreatitis (22) or persistent pain (10) without chronic inflammation or fibrosis. Twenty-nine have been treated by transduodenal sphincteroplasty of the accessory papilla; 22 were stenotic (0.75 mm or less) and 7 nonstenotic. Among 25 patients observed for longer than 6 months after surgery, the relief of pain and pancreatitis has been good in 17, fair in 1, and poor in 7. There was no difference between accessory papillotomy alone (10-0-3) v papillotomies of both accessory and major papillae (7-1-4). Patients with stenosis (16-1-1) fared better (p less than 0.001) than those without stenosis (1-0-6). Those presenting with discrete attacks (12-1-2) also fared better (p less than 0.05) than those presenting with chronic pain (5-0-5). The other eight patients (two women, six men, median age 28) had chronic pancreatitis proven by pancreatography and surgical biopsy. In this group, treatment by sphincteroplasty of the accessory papilla failed, and seven patients eventually required a pancreaticojejunostomy (3), distal pancreatectomy (2), or total pancreatectomy (2). In pancreas divisum, pancreatitis is caused by stenosis at the accessory papilla of Santorini. There may be progression from recurrent acute pancreatitis to irreversible fibrosis in some cases. Sphincteroplasty is effective for recurrent acute pancreatitis, but ductal drainage or resection becomes necessary once chronic pancreatitis is established. A preoperative test for stenosis of the accessory papilla is needed to identify patients whose symptoms are genuinely caused by their pancreas divisum.

Acute Disease↗
PubMed1981

Association of pancreas divisum and pancreatitis, and its treatment by sphincteroplasty of the accessory ampulla.

All 519 endoscopic pancreatograms performed in the Massachusetts General Hospital Endoscopy Unit from 1973 to 1980 were reviewed. Patients who underwent pancreatograms for documented pancreatitis were more likely (p less than 0.005) to have the duct anomaly pancreas divisum (12%) than those patients who had pancreatograms incidental to cholangiography (2.9%), or for unexplained chronic abdominal pain (3.3%). When compared with patients with pancreatitis and normal duct development, patients with pancreatitis associated with pancreas divisum tended to be younger and to have a clinical pattern of recurrent acute attacks of pancreatitis. Nine patients with recurrent pancreatitis or severe chronic abdominal pain and pancreas divisum were treated by surgical sphincteroplasty of the accessory ampulla. Five of the 6 patients with documented acute attacks of pancreatitis received good to excellent pain relief and had no further attacks of acute pancreatitis. None of the 3 patients with severe chronic abdominal pain without objective evidence of pancreatitis derived significant benefit. Accessory ampulla sphincteroplasty seems to relieve pain and prevent further attacks of acute pancreatitis in patients with pancreas divisum and recurrent pancreatitis. This response to sphincteroplasty adds further credence to the stated association between pancreas divisum and pancreatitis.

Acute Disease↗
PubMed1980

Observations on management of choledochoduodenal fistula due to penetrating peptic ulcer.

Perforation into the biliary tract is a rare complication of benign peptic ulcer disease. This report describes our experience with 4 patients having this problem. The resulting choledochoduodenal fistula itself causes no unique symptoms in most cases. The diagnosis, hithertofore unsuspected, is most commonly made during barium examination of the upper gastrointestinal tract in patients with typical complaints of ulcer disease. Endoscopy and retrograde cholangiography may be useful to define the pathologic anatomy and to distinguish peptic ulcer disease from primary biliary tract disease or malignant ulcer. Medical management of the underlying ulcer disease with cimetidine and antacids usually suffices to relieve symptoms and to allow healing of the fistula. Surgery becomes necessary if biliary stenosis or cholangitis occurs, or if other aspects of the ulcer disease mandate operative treatment.

Aged↗
PubMed1980

Long-term patency, pancreatic function, and pain relief after lateral pancreaticojejunostomy for chronic pancreatitis.

Ten patients, all with intractable pain due to chronic pancreatitis, were selected for treatment by lateral pancreaticojejunostomy (modified Puestow procedure) after preoperative endoscopic pancreatography in each had revealed dilatation of the main pancreatic duct. Follow-up endoscopic pancreatograms performed 1 yr after surgery show a patent anastomosis in all 10 patients. Eight of these 10 are largely or completely pain-free, but 2 continiue to have pain without improvement after the operation. Surgical success in relieving pain was accompanied neither by improvement in pancreatic function, nor by protection against its further deterioration: Whereas 2 patients had malabsorption and 3 were diabetic preoperatively, 6 had malabsorption and 5 had diabetes postoperatively. This progression of exocrine or endorine pancreatic insufficiency indicates that decompression of the dilated pancreatic duct, although an effective means for relief of pain in chronic pancreatitis, does not prevent continuing destruction of pancreatic glandular tissue.

Adult↗
PubMed1979

Extrahepatic biliary obstruction caused by metastatic breast carcinoma.

We describe our experience with seven patients who had extrahepatic biliary obstruction caused by metastatic breast cancer. The interval from the original diagnosis of breast cancer to the development of jaundice averaged 40 months, with a range of 9 months to 8 years. All patients were treated with surgical decompression, radiation, transhepatic catheter drainage, chemotherapy, or a combination of these modalities. Resolution of jaundice was achieved in six patients. Prolonged survival was realized in three; one patient lived for more than 6 years after surgical bypass, and two are alive and well at present (greater than 11 months after relief of biliary obstruction). Extrahepatic biliary obstruction by metastatic breast carcinoma should be distinguished from jaundice due to hepatic parenchymal destruction by this tumor; while the latter implies end-stage cancer, the former has the potential for significant palliation and prolonged survival.

Bile Duct Neoplasms↗
PubMed1977

Angiodysplasia of the right colon: a cause of gastrointestinal bleeding.

Thirty-four patients with intermittent lower gastrointestinal bleeding were diagnosed angiographically as having angiodysplasia of the cecum and right colon. Repeated barium and endoscopic examinations were negative. Right colectomy was performed on 17 patients, who were followed postoperatively for up to 7 years. Of these, four patients rebled, two of whom had angiographic evidence of related lesions involving other parts of the colon and terminal ileum. Silicone rubber injection and tissue-clearing techniques on the specimens have facilitated the pathologic identification of these lesions. Histologically, they are dilated submucosal veins and arteries associated with areas of overlying mucosal thinning and occasional ulcerations. Although the pathogenesis of the lesion is unknown, we think they are acquired rather than congenital and result from chronic submucosal arteriovenous shunting secondary to mucosal ischemia. Of the 34 patients, 17 had a history of cardiac disease.

Aged↗
PubMed1977

The value of endoscopic retrograde pancreatography in the management of pancreatic ascites.

A case of pancreatic ascites is presented in which the preoperative use of endoscopic retrograde cannulation of ampulla of Vater (ERCP) precisely located the site of pancreatic duct disruption and thus directed the choice of operation best suited to this patients. We suggest that in this form of ascites preoperative ERCP may aid in the selection of those patients whose lesions are surgically correctable.

Ascites↗
PubMed1976

Persistent obstructive jaundice, cholangitis, and biliary cirrhosis due to common bile duct stenosis in chronic pancreatitis.

Long strictures of the intrapancreatic portion of the common bile duct were found in 6 patients with chronic pancreatitis. These strictures were responsible for painless obstructive jaundice, recurrent cholangitis, secondary biliary cirrhosis, and chronic abdominal pain difficult to distinguish from that caused by pancreatitis. Endoscopic retrograde cholangiopancreatography and intraoperative cholangiography were invaluable in making the diagnosis and in planning surgical correction. Decompression of the biliary tree by anastomosis of the gallbladder or common duct to the small intestine completely relieved symptoms and allowed liver function to improve significantly. Common duct stricture as a complication of chronic pancreatitis should be considered in the differential diagnosis of extrahepatic biliary obstruction and whenever surgical treatment of chronic pancreatitis is contemplated.

Adult↗
PubMedDate not supplied

Endoscopic palliation of obstructive esophagogastric malignancy.

To investigate the efficacy of alternative endoscopic palliative therapies for obstructive esophagogastric malignancy, the experience of 53 patients treated between 1979 and 1986 was analyzed. Forty-seven patients had placement of intraesophageal prostheses. Ten patients had prostheses placed after neodymium:YAG laser therapy. In four of these patients, prosthesis placement was planned as part of the initial therapy. Twelve patients initially received laser therapy. In six, recurrent tumor was treated with intraesophageal prostheses 3 to 24 weeks after laser treatment. Comparing neodymium:YAG laser therapy to placement of the prosthesis, both techniques provided similar improvement in dysphagia. Patients receiving prostheses required less additional treatment for dysphagia. Life table analysis comparing survival rates from diagnosis to death showed no difference. The palliation provided by prostheses and neodymium:YAG laser appears to be quite similar; however, the prosthesis seems to be more lasting and require fewer resources.

Adenocarcinoma↗
PubMedDate not supplied

Methotrexate in Crohn's disease: results of a randomized, double-blind, placebo-controlled trial.

BACKGROUND/AIMS: Immunosuppression with methotrexate may be useful in the treatment of Crohn's disease. We tested the efficacy of methotrexate in refractory Crohn's disease in a randomized, controlled trial. METHODOLOGY: Randomized, double-blind placebo-controlled trial of methotrexate in 33 patients with steroid-dependent Crohn's disease, 33% of whom had previously failed therapy with 6-mercaptopurine. Patients were given placebo or oral methotrexate 15 mg/week, or adjusted up to 22.5 mg/week, for up to 1 year or until treatment failure. Outcome was assessed by reduction in prednisone dosage, Crohn's Disease Activity Index, hospital admission, and laboratory parameters. RESULTS: Four patients were dropped from the study for non-compliance and one because of intercurrent illness, and 28 patients could be evaluated. Fewer methotrexate-treated patients (6/13 or 46%) had flares of Crohn's disease as compared to placebo-treated patients (12/15 or 80%), but this did not achieve statistical significance (p<0.1). There was a non-significant trend toward an increased number of significant side effects in the methotrexate-treated patients (3/13 or 23%) as compared to the placebo-treated patients (0/15 or 0%) (p<0.2). Laboratory indices of inflammation did not differ between the two groups. CONCLUSIONS: The methotrexate-treated group showed a trend toward fewer Crohn's disease flares, balanced by an increased number of significant side effects.

Administration, Oral↗