Clinics in gastroenterology最新文献

Since 1973, biliary calculi can be extracted from the common bile duct after endoscopic papillotomy (EPT). The success rate amounts to 90%. Complications occur in 7%, and 1% of the patients will die. The most frequent complication is haemorrhage (30%), but only 10% of these cases require surgery. Results of EPT are more favourable than those of surgery. Prophylactic antibiotics are not necessary, but in the event of fever, β-lactam antibiotics or modern cephalosporins are indicated.

When stone extraction fails, several different methods of lithotripsy can be employed: endoscopic mechanic, endoscopic electrohydraulic, and the recently developed extracorporally generated shock-waves. Lithotripsy will succeed in 80–90% of cases. As late sequelae after EPT cannot be completely excluded, dilatation of the papilla by balloon catheter was developed. However, the number of patients treated is still very small. When these methods fail or are not available, common bile duct stones can be chemically dissolved. Irrigation media are infused into the biliary tree via a nasobiliary tube after EPT or percutaneous transhepatic cholangiography. The substances used are cholesterol solvents such as mono-octanoin, GMOC or MTBE. A buffered 1% EDTA solution is used for calcium bilirubinate stones. Stone dissolution will succeed in 50–70% of cases. Side-effects include cholangitis and duodenitis.

Endoscopy should not be the sole final arbiter in controlled clinical trials of peptic disorders. Data on the response of symptoms to treatment and the occurrence of side-effects may be not as 'hard’ as endoscopically assessed 'healing’ and 'relapse’, but may be clinically more meaningful. Furthermore, in most recent trials, 'healing’ and 'relapse’ were poorly defined; important information on residual mucosal lesions after healing was often neglected.

The papilla of Vater, diminutive as it may be, forms the nidus for a variety of clinical disorders. Owing to its crucial location at the confluence of the bile and pancreatic ducts, many of these clinical disorders lead to an impedance to the flow of secretions from the liver and pancreas. Thus, most symptomatic papillary disorders present with a rather predictable and monotonous conglomeration of symptoms. The common clinical presentations of papillary disorders include abdominal pain, jaundice, fever, pruritus and pancreatitis. Rarely, gastrointestinal bleeding leading to anaemia and weight loss may also be observed.

The advent of ERCP rekindled interest in diseases of the papilla. The major duodenal papilla is more accessible now than ever before. The endoscopist can visualize the papilla within minutes and take an appropriate tissue sample using different biopsy techniques. Definitive diagnosis is thus possible in most patients with papillary tumours. Along with ERCP, the miniaturization of a perfusion system with minimal compliance enabled us to accurately evaluate sphincter of Oddi (SO) dynamics. This in turn gave us a wealth of information on the physiology of the sphincter of Oddi. In addition, ERCP manometry led to a resurgence of interest in SO dysfunction, especially papillary stenosis. Several characteristic manometric abnormalities have been identified recently. Finally, the introduction of endoscopic sphincterotomy (ES), nearly a decade ago, opened a new chapter in the therapeutic approach towards papillary disorders. While the technique was initially applied in the management of common bile duct stones in postcholecystectomy patients who were high operative risks, the indications for ES steadily increased during the past decade. Experience over the years led us to be convinced that ES is equally effective in the management of a variety of papillary disorders, including choledochoduodenal fistula, choledochocele, papillary tumours and SO dysfunction. Most recently, other ancillary procedures such as endoprosthesis insertion have emerged as yet another useful therapeutic modality. Such internal biliary stents have been shown to be suitable in establishing biliary drainage in ampullary neoplasms when the operative approach is considered risky.