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A 30 YEAR WOMEN WITH INTRACTABLE BILIARY COLIC
CASE REPORT: This 30 year women developed severe pain right upper quadrant for last 10 days. She sought many consultations and was given intravenous analgesics both (nonnarcortic and narcotic). Pain did not subside and she sought my consultation. Examination revealed her to be in agony with severe upper abdominal pain. General physical examination was otherwise unremarkable. Abdominal examination revealed mild tenderness in right hypochondrium with doubtful Murphy's sign. Urgent abdominal ultrasound showed a linear structure in bile ducts making slow writhing movements. The structure had an anechoic tube (alimentary canal) inside suggestive of a large Ascarid. Urgent ERCP was performed and bile duct and pancreatic duct cannulated selectively. Pancreatic duct was normal. Bile ducts contained a long linear filling defect extending from lower end of common bile duct to right intrahepatic duct (see image gallery for ERCP plate). A basket was introduced in the duct (see video clip) and the linear structure was engaged with soft closure and extracted out of the bile duct. Accompanying the basket was a 25 cm thick highly motile Ascarid. To recover the worm, endoscope was withdrawn along with the basket and the friendly catch. While the endoscope was being withdrawn and the basket was in the duodenum with the worm out of bile duct, patient indicated of relief of abdominal pain. A relook cholangiogram showed no more structures in the duct. She was given antihelmintic therapy and passed hundreds of worms with the feces. The worms recovered form stools were both male and female population and varied in length and size. However the lone worm recovered form bile ducts was the longest and the thickest male worm. The phenomenal behavior of this ubiquitous infection remains unexplained.
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Polycystic ovary syndrome (PCOS, also known clinically as Stein-Leventhal syndrome), which is an endocrine disorder that affects 5--10% of women. It occurs amongst all races and nationalities, is the most common hormonal disorder among women of reproductive age, and is a leading cause of infertility. The symptoms and severity of the syndrome vary greatly between women. While the causes are unknown, insulin resistance (often secondary to obesity) is heavily correlated with PCOS.
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Pancreatic pseudocyst drainage was the first therapeutic application of EUS. The cyst is punctured under ultrasound guidance, contrast injected, and a guidewire inserted. Initial dilation to 8mm is performed over the wire The EUS scope is then exchanged over the wire for a forward viewing endoscope.... A second dilation to 18mm is performed. This enables entry of the endoscope into the cyst perform cystoscopy, debridement if necessary, and insertion of multiple large bore double pigtail stents. The curved linear array-or CLA—echoendoscope has oblique viewing optics located proximal to an oblique scanning transducer. The accessory exits from the shaft of the echoendoscope at an ablique angle, adjustable between 15 and 30 degrees. There are several technical limitations using this echoendoscope. The oblique angle of exit results in a weekend transfer of force when advancing the accessory, difficult deployment of larger bore accessories, and in instrument tunneling effect relative to the bowel wall. There is the potential loss of access during endoscope exchange. A novel CLA echoendoscope was developed by the Olympus Corporation that shifts the orientation of endoscopic and ultrasound views from oblique to forward viewing. The channel is therapeutic at 3.7mm Note that the working channel is located adjacent to the ultrasound transducer at the endoscope tip. The accessory exits the working channel in the axis of the shaft. Shown here are balloon inflation and deployment of a Dormia basket. We report on the use of the prototype forward viewing echoendoscope in six consecutive patients who were referred for pancreatic cyst drainage. Here you see endoscopic view-indistinguisable from that of a gastroscope-showing a bulge where the cyst impinges against the posterior gastric wall. Power Doppler is switched on and highlights multiple vessels interposed in the wall This allows selection of a safe vessel-free window for a cyst puncture A 19 G needle is advanced into the cyst lumen. A sample of contents is aspirated for fluid analysis. A guidewire under ultrasound guidance into the cyst. An 18mm balloon is coaxially thread over the wire and advanced across the cyst wall, Note that resistance is encountered, but the forward transfer of force overcome this. The dilation is performed under forward viewing endoscopuc and ultrasound guidance. As the balloon is maximally inflated we see the cystgastrostomy open up. The balloon is then deflated while simultaneously advancing the scope into the cyst cavity. Cystoscopy isnow performed showing the cyst contents to be filled with pasty wall-adherent necroses. Pulsed power Doppler is switched on we can see and hear arterial flow vessels within the wall of the cyst. This identifies sensitive areas at bleeding risk when performing debridement In this case vigorous water jet irrigation is performed through an accessory water irrigation channel built into the echoendoscope. This issued to clear nonadherent debris. Our experience has shown that it is not necessary to actively remove wall-adherent debris using extraction tools as such Dormia or Roth net basket to achieve cyst resolution. Three large bore 10 Fr double pigtail stents are now inserted into the cyst under direct endoscopic guidance. The first stent is delivered over a guide catheter. The second stent. And the third stent All three stents are deployed. Finally, a nasocystic catheter is inserted for maintenance irrigation. In another patient we used the Cook Cystome to perform cystgastrostomy. We have found the Cystotome easy to delivery through the forward viewing echoendoscope. As shown, we advance the Cystotome into the cyst while applying diathermy. This is performed under and endoscopic guidance, entering the cyst at a near perpendicular orientation. After entry, the Cystotome is removed and cyst fluid gushes from the cystagastrotomy site.
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anchoring suture reduces the impairment of the anastomotic blood flow that is caused by gravitational tension and so is useful to protect the esophagojejunostomy after total gastrectomy.
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Current treatment is a combination of pegylated interferon-alpha-2a or pegylated interferon-alpha-2b (brand names Pegasys or PEG-Intron) and the antiviral drug ribavirin for a period of 24 or 48 weeks, depending on hepatitis C virus genotype. In a large multicenter randomized control study among genotype 2 or 3 infected patients (NORDymanIC),[35] patients achieving HCV RNA below 1000 IU/mL by day 7 who were treated for 12 weeks demonstrated similar cure rates as those treated for 24 weeks.[36][37]
Pegylated interferon-alpha-2a plus ribavirin may increase sustained virological response among patients with chronic hepatitis C as compared to pegylated interferon-alpha-2b plus ribavirin according to a systematic review of randomized controlled trials .[38] The relative benefit increase was 14.6%. For patients at similar risk to those in this study (41.0% had sustained virological response when not treated with pegylated interferon alpha 2a plus ribavirin), this leads to an absolute benefit increase of 6%. About 16.7 patients must be treated for one to benefit (number needed to treat = 16.7; click here [39] to adjust these results for patients at higher or lower risk of sustained virological response). However, this study's results may be biased due to uncertain temporality of association, selective dose response.
Treatment is generally recommended for patients with proven hepatitis C virus infection and persistently abnormal liver function tests.
Treatment during the acute infection phase has much higher success rates (greater than 90%) with a shorter duration of treatment; however, this must be balanced against the 15-40% chance of spontaneous clearance without treatment (see Acute Hepatitis C section above).
Those with low initial viral loads respond much better to treatment than those with higher viral loads (greater than 400,000 IU/mL). Current combination therapy is usually supervised by physicians in the fields of gastroenterology, hepatology or infectious disease.
The treatment may be physically demanding, particularly for those with a prior history of drug or alcohol abuse. It can qualify for temporary disability in some cases. A substantial proportion of patients will experience a panoply of side effects ranging from a 'flu-like' syndrome (the most common, experienced for a few days after the weekly injection of interferon) to severe adverse events including anemia, cardiovascular events and psychiatric problems such as suicide or suicidal ideation. The latter are exacerbated by the general physiological stress experienced by the patient.
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