[show abstract][hide abstract] ABSTRACT: In patients with chronic hepatitis C, determination of hepatitis C virus (HCV) genotype could be routinely run in the future to tailor treatment schedules. The suitabilities of two versions of a serological, so-called serotyping assay (Murex HCV Serotyping Assay version 1-3 [SA1-3] and Murex HCV Serotyping Assay version 1-6 [SA1-6]; Murex Diagnostics Ltd.), based on the detection of genotype-specific antibodies directed to epitopes encoded by the NS4 region of the genome, for the routine determination of HCV genotypes were studied. The results were compared with those of a molecular biology-based genotyping method (HCV Line Probe Assay [INNO-LiPA HCV]; Innogenetics S.A.), based on hybridization of PCR products onto genotype-specific probes designed in the 5' noncoding region of the genome, obtained with pretreatment serum samples from 88 patients with chronic hepatitis C eligible for interferon therapy. Definitive genotyping was performed by sequence analysis of three regions of the viral genome in all samples with discrepant typing results found among at least two of the three assays studied. In all instances, sequence analysis confirmed the result of the INNO-LiPA HCV test. The sensitivity of SA1-3 was 75% relative to the results obtained by the genotyping assay. The results were concordant with those of genotyping for 92% of the samples typeable by SA1-3. The sensitivity of SA1-6 was 89% relative to the results obtained by the genotyping assay. The results were concordant with those of genotyping for 94% of the samples typeable by SA1-6. Overall, SA1-6 had increased sensitivity relative to SA1-3 but remained less sensitive than the genotyping assay on the basis of PCR amplification of HCV RNA. Cross-reactivities between different HCV genotypes could be responsible for the mistyping of 8 (SA1-3) and 6% (SA1-6) of the samples. Subtyping of 1a and 1b is still not possible with the existing peptides, but discriminating between subtypes may not be necessary for routine use.
Journal of Clinical Microbiology 08/1997; 35(7):1734-9. · 4.07 Impact Factor
[show abstract][hide abstract] ABSTRACT: Although long-term results of endoscopic sphincterotomy (ES) have been poorly estimated, extended indications of ES have been proposed, especially in young patients. The aim of this study was to assess late biliary complications of ES.
Between 1981 and 1986, 169 patients younger than age 70 (55+/-11.8 years; range, 24-70 years; male-female sex ration, 0.55) underwent ES for choledocholithiasis. One hundred fifteen patients (68%) underwent cholecystectomy. Long-term data were obtained retrospectively from the patients and general practitioners.
Information was obtained for 156 patients, 2 of whom died within 1 month (one ES-related death). The mean follow-up for 154 patients was 9.6+/-3.3 years (range 8-13 years); 138 patients had no biliary symptoms. During follow-up, 16 patients experienced biliary symptoms; 2 of these patients underwent elective cholecystectomy, 3 had malignant strictures, 1 had a complicated cirrhosis, and 1 had a benign stricture related to the previous cholecystectomy. Nine patients developed potentially ES-related biliary symptoms. Second endoscopic exploration showed papillary stenosis in 3 patients (with stones in 2 patients) and recurrent bile duct stones in 3 others. Two patients had sine materia cholangitis, and 1 patient developed liver abscesses.
Long-term ES-related complications seem to be rare, ES could reasonably be included in management strategies of choledocholithiasis, even in young patients.
[show abstract][hide abstract] ABSTRACT: Nonsurgical alternatives in biliary diseases have not been studied in large series of patients with cirrhosis. Our aim was to determine the indications and results of endoscopic treatment in this subset of patients.
Fifty-two patients (36 men, 16 women-Child-Pugh Class A, 18; B, 22; C, 12) aged 63 +/- 18 years underwent endoscopic sphincterotomy (ES) between 1988 and 1993. Antibiotic prophylaxis was routinely carried out and coagulopathy was corrected before ES when required. The data were collected retrospectively up to 30 days after ES.
ES succeeded in 98% of the patients (12 cases of needle-knife papillotomy). Twenty-nine patients (55.7%) had choledocholithiasis, 18 had biliary strictures (12 malignant), and 5 had pancreatic or other biliary diseases. Five days after ES, morbidity was 13.5% and mortality was 7.7%. At 1 month, morbidity was 22.9% and mortality 12.5%. Only endoscopic procedures and Ineffective drainage were seen to be significant risk factors or morbidity. The results of the subgroup of cirrhotic patients with choledocholithiasis (n = 29) were compared with those of matched noncirrhotic patients (n = 58). The cirrhotic and noncirrhotic patients treated for choledocholithiasis showed similar results for stone clearance, morbidity, and mortality.
ES is a safe and effective procedure for treating choledocholithiasis in cirrhotic patients. ES can therefore be considered as an alternative to surgery in Child class A and B patients and must be preferred for Child class C patients with life-threatening biliary complications.
[show abstract][hide abstract] ABSTRACT: To evaluate the value of biliary carcino-embryonic antigen (CEA) in the differential diagnosis of malignant and benign hepatopancreatobiliary disease.
One hundred patients were prospectively studied. Benign diseases were present in 39% of the patients while 61% had malignant diseases.
Samples of serum were taken from all patients just before endoscopic retrograde cholangiopancreatography (ERCP) and samples of biliary CEA were obtained during ERCP.
The sensitivity of serum CEA and carbohydrate antigen 19-9 (CA 19-9) in detecting malignancy were 50% and 92%, respectively, while the respective specificities were 95% and 72%. The mean biliary CEA level of the benign group was significantly different from that of the malignant group (35.7 +/- 8.7 ng/ml vs 268 +/- 85.5 ng/ml), but there was considerable overlap between the two groups. With a cut-off level of 20 ng/ml, the sensitivity and specificity were 84% and 64% respectively. The mean bilirubinaemia value was significantly higher in malignant disease than in benign disease (57.4 +/- 13.9 mumol/l vs 235 +/- 19.8 mumol/l). Multidimensional analysis indicated that only bilirubinaemia (P < 109-3)) was independently predictive of malignant disease.
Biliary CEA assessment seems useless in distinguished between benign and malignant causes of cholestasis.
European Journal of Gastroenterology & Hepatology 03/1996; 8(2):131-4. · 1.92 Impact Factor
[show abstract][hide abstract] ABSTRACT: Endoscopic sphincterotomy is sometimes done unnecessarily in patients with suspected choledocholithiasis. Our aims were to assess the diagnostic accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography (ERC) and to find out whether endoscopic ultrasonography may help to prevent unnecessary sphincterotomy or surgical explorations.
We recruited 119 patients aged 70.4 (SD 16.1) years with strongly suspected choledocholithiasis who presented to our endoscopy unit between January, 1994, and January, 1995. During the same spell of sedation or within 2 h of each other, endoscopic ultrasonography and ERC were carried out by investigators unaware of the patient's history. Endoscopic sphincterotomy with instrumental exploration was then done as the gold standard for the presence or the absence of stones.
78 (66%) patients had choledocholithiasis; 17 (14%) had other bileduct diseases; 24 (20%) had a clear bileduct or did not require an invasive endoscopic procedure. The sensitivity of endoscopic ultrasonography was 93%, specificity 97%, positive predictive value 98%, and negative predictive value 88%. The corresponding values for ERC were 89%, 100%, 100%, and 83%. There were five false-negative cases by endoscopic ultrasonography (of which three were also negative with ERC) and one false-positive. The morbidity rate was 4.1%.
We conclude that endoscopic ultrasonography is at least as sensitive as ERC. Endoscopic ultrasonography may prevent inappropriate invasive explorations of the common bileduct.
The Lancet 02/1996; 347(8994):75-9. · 39.06 Impact Factor
[show abstract][hide abstract] ABSTRACT: The cholangiographic features of intrahepatic bile ducts associated with cirrhosis or fibrosis are not well known. In order to achieve a radiological-pathological correlation, we studied nine livers with fibrosis or cirrhosis excised at autopsy. Cholangiograms were obtained within 24 hr after death from the nonfixed liver and multiple tissues samples were taken for histologic examination. Radiological data were interpreted by two independent investigators blinded to the clinical and histological findings. Cirrhosis (alcoholic in 4, posthepatitis in two) was observed in six livers, fibrosis (alcoholic in 2, posthepatitis in one) in three. No liver with fibrosis had cholangiographic abnormalities. In contrast, cholangiography of all livers with cirrhosis was abnormal. Abnormalities were a diminished arborization, a decrease of the distal opacification, an irregularity of caliber, and a tortuous course of the bile ducts. Histological study showed that the irregular and tortuous course were due to compression of the bile ducts by regenerative nodules. Furthermore, a thick fibrosis was organized around the bile ducts. In conclusion, fibrosis alone was not associated with cholangiographic abnormalities. In cirrhotic livers, intrahepatic bile ducts showed an irregular and tortuous course, a diminished arborization and a decrease of the distal opacification. These abnormalities were secondary to the presence of regenerative nodules and fibrosis organized around the bile ducts.
Digestive Diseases and Sciences 11/1995; 40(10):2128-33. · 2.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: To characterize a subgroup of patients treated with endoscopic sphincterotomy (ES) for a suspected common bile duct lithiasis (CBDL) that was not confirmed and to compare it with the subgroup with confirmed CBDL.
Over 18 months, ES was successful in 245 consecutive patients (age 23-97, mean 75 yr, SE 17 yr) with suspected CBDL; 159 patients had CBDL (group 1), and 86 did not (group 2), as confirmed by CBD exploration. Fifty-nine percent of the patients in group 1 and 76.7% of the patients in group 2 had gallbladder in situ. Both groups were different for age (p < 0.001), prevalence of chronic alcoholism (p < 0.001), gallbladder in situ (p < 0.01), and gallbladder stones (p < 0.05). Patients from group 1 had two or more presenting symptoms suggestive of CBDL more often than patients from group 2 (p < 0.05), and pancreatitis was a more frequent presenting manifestation in group 2 (p < 0.0001). Overall morbidity and mortality were not different between groups, but acute cholecystitis developed in six patients from group 2 and in one patient from group 1 (p < 0.01). In a univariate analysis, only elevated alkaline phosphatase and a dilated common bile duct were positively discriminant for the diagnosis of CBDL; chronic alcoholism was negatively discriminant for the diagnosis of CBDL. In a multivariate analysis, only chronic alcoholism and a dilated bile duct were found to be independently discriminant.
The risk of ES-related complications in the group without CBDL suggests that the selection of patients should be improved by a better use of preoperative criteria.
The American Journal of Gastroenterology 06/1995; 90(5):727-31. · 7.55 Impact Factor
[show abstract][hide abstract] ABSTRACT: Ulcer recurrence is probably related to residual Helicobacter pylori (H pylori). Histological examination and culture are considered to be the most specific tests. CLO test is a rapid but less specific test, which is usually used as an alternative test to culture. The aim of this study was to investigate the efficiency of a simplified polymerase chain reaction (PCR) assay as a procedure for the diagnosis of gastric H pylori infection of patients. Biopsy specimens were obtained from antral mucosa of 58 patients at endoscopy and submitted to four tests for detection of H pylori. The bacteria were found in 53%, 43%, 48%, and 50% of patients according to the results of PCR, CLO test, culture, and histological examination. Twenty three patients had both negative histology and negative culture and PCR was negative in all of these. Thirteen patients were not classified because only histology or culture was positive and 10 of these had a positive PCR test. When the diagnosis of H pylori was established by agreement with both histology and culture or three positive tests out of four, 29 patients were H pylori positive (28 having had three positive tests and one displaying positive histology and culture), and 26 were negative, and three undetermined. PCR proved the most sensitive and specific test. These results suggest the simplified PCR assay may be a valuable test for the detection of H pylori.
[show abstract][hide abstract] ABSTRACT: We report here on our experience of clinically relevant bleeding after endoscopic sphincterotomy (ES). Relevant bleeding was defined by the occurrence of (a) hematemesis or melena and (b) at least a two-point drop in hemoglobin, with no other bleeding source on endoscopy. These two criteria were met in 16 patients between 1983 and 1992. They represented 0.65% of all ES procedures performed during this period. Bleeding occurred immediately after ES in five cases, and was delayed in 11 cases from one to eight days (mean two days). Patients were retrospectively classified into three groups according to the severity of bleeding and subsequent clinical management. In six cases (group 1), bleeding developed slowly without shock and stopped spontaneously. In five cases (group 2), bleeding developed rapidly with melena and a drop in hemoglobin, but without shock. These patients were successfully managed with sclerotherapy without any further complications. The five patients in Group 3 had brisk bleeding with hematemesis and shock. Endoscopic hemostasis could not be performed; emergency arteriography disclosed active bleeding in four patients, and embolization of the gastroduodenal artery was performed. Bleeding stopped in all patients. Billroth II anastomosis appeared to be the only factor associated with an increased risk of clinically relevant bleeding. It was possible to control bleeding following ES using endoscopic or angiographic hemostasis, surgery being avoided in all cases.
[show abstract][hide abstract] ABSTRACT: Two cases of psoas abscess complicating acute necrotizing pancreatitis are reported. These cases were particular because the abscesses exteriorized in the groin and symptoms were misleading. The abscesses were detected late, three and five months after the beginning of the pancreatitis respectively. The difficulties in diagnosis and the long delay to diagnosis are emphasized as possible sources of superinfection.
Gastroentérologie Clinique et Biologique 02/1994; 18(11):1028-32. · 1.14 Impact Factor
[show abstract][hide abstract] ABSTRACT: From June 1991 to September 1992, 16 patients (mean age, 72 +/- 5 years) were treated with intra-corporeal laser lithotripsy (ICL). Thirteen patients had choledocholithiasis with at least one stone larger than 20 mm; 3 patients had intra-hepatic lithiasis. All other methods, including mechanical lithotripsy, extra-corporeal lithotripsy (1 case), and intra-corporeal electrohydraulic lithotripsy (1 case), had failed to clear the bile ducts. Approaches for ICL were choledochoscopy with a "baby" endoscope via an existing sphincterotomy (8 cases), retrograde cholangioscopy with a gastroscope through a choledochoduodenal anastomosis or a sphincterotomy in patients with a gastrojejunal anastomosis (5 cases), and trans-hepatic cholangioscopy with a fibercholangioscope (3 cases, in 1 of which retrograde and trans-hepatic approaches were combined). Free bile ducts were obtained in 14/16 (87.5%) patients after a mean of 1.66 ICL sessions per patient. Mortality and laser-related morbidity did not occur; endoscopy-related morbidity was 12.5% for minor complications (1 transitory fever, 1 mild and transitory hemobilia) and 6.25% for major complications (1 post-sphincterotomy hemorrhage). Mean length of hospital stay was 11.5 +/- 2.5 days. We conclude that although it is rarely indicated and is expensive, ICL does offer a limited treatment option in selected patients. It allows the complete relief of complex biliary lithiasis. Morbidity is related to maneuvers preceding ICL, not to ICL itself.