Rôle diagnostique de l’écho-endoscopie dans la pancréatite aiguë

In approximately 20% of patients with acute pancreatitis, a cause is not established by history, physical examination, routine laboratory testing or abdominal imaging. Recent studies suggest that microlithiasis is causative in up to 60% of patients with an unexplained acute pancreatitis (UAP) and gallbladder in situ. In the others, many factors play an etiological role in idiopathic pancreatitis, including pancreatic tumors, early chronic pancreatitis, pancreas divisum or annular pancreas, choledochocele, intraductal papillary mucinous tumours (IPMT), an anomalous pancreatobiliary junction or sphincter of Oddi dysfunction (SOD). The close proximity of the endoscopic ultrasound probe (EUS) to the pancreas and biliary tract results in superior spatial resolution compared with CT scan and MRI. The diagnostic yield of EUS in unexplained acute pancreatitis is 80%. EUS appears to be diagnostic in the majority of patients with previously unexplained pancreatitis and offers an alternative to MRI and endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with unexplained acute pancreatitis.     

Indications et choix de technique de drainage en cas de pancréatite aiguë grave ?

Definition of severe acute pancreatitis includes organ failure or/and pancreatic or peripancreatic fluid collections. Three types of emergency drainage can be discussed in such a situation: Biliary drainage by early endoscopic sphincterotomy, transpapillary endoscopic drainage in case of early pancreatic fistula, and peripancreatic fluid collections drainage using four different approaches (percutaneous radiologic drainage, retroperitoneal drainage by surgical laparoscopy, transgastric or transduodenal endoscopic drainage and open surgical necrosectomy). The purpose of this mini-review is to focus on the current indications and choices of these different types of drainage approach.     

Traitement endoscopique d’une fistule colique due à une pancréatite aiguë nécrosante : à propos d’un cas

Severe acute pancreatitis is associated with a colonic fistula in about 3–5% of cases. The gold-standard is a surgical treatment, often with temporary colostomy or ileostomy. We report the case of a 37-year-old man with acute necrotizing pancreatitis with colic fistula treated by endoscopic and percutaneous drainage. Initially, a transgastric drainage with placement of two pigtail stents was achieved. Given the persistence of sepsis, the patient was referred to our center. Endoscopic necrosectomy was performed and a nasocystic drain allowed to wash the necrosis cavity. Cystcolonic fistula has been found during the opacification. Medical treatment was then carried out with antibiotics, antifungal, somatostatin derivatives and percutaneous drainage under CT-scanner of a collection in the left flank. After iterative washes through the two drains, opacification control showed no persistent fistula. Drains were removed without recurrence to date of the colonic fistula.     

Épiglottites aiguës sévères de l’adulte

Historically, acute epiglottitis occurred in young children and the most common causative organism was Haemophilus influenzae type b (Hib). Since the introduction of the Hib vaccine, the incidence of epiglottitis among children has declined, whereas the incidence among adults has increased. The typical profile of an adult patient with acute epiglottitis seems to be a middle-aged patient with a male predominance. Contrary to the classical presentation of epiglottitis in children, adult patients present with nonspecific oropharyngeal symptoms. Thus, diagnosis can be delayed or missed in its initial stage. Flexible laryngoscopy is used to confirm the diagnosis, showing inflammation of the epiglottis and the adjacent supraglottic structures. Most patients can be closely monitored in the Intensive Care Unit, without the need for an airway intervention. However, in severe epiglottitis, the focus of treatment is the maintenance of a patent airway, using intubation or tracheotomy. Mortality remains low, but hypoxic cardiac arrest can occur without warning, due to airway obstruction.     

Syndrome de détresse respiratoire aiguë et maladie de Churg et Strauss

We report a case of acute respiratory distress syndrome (ARDS) in a 37-year-old man. Hypoxemia was refractory despite conventional treatment of ARDS, but the evolution was satisfactory after corticosteroid therapy. Biological data and the clinical evolution led us to the diagnosis of Churg-Strauss syndrome. This case incites us to reiterate that after having eliminating the usual causes of ARDS, the assumption of a systemic disease should be considered in order to begin the appropriate treatment as rapidly as possible.     

Le décubitus ventral dans le syndrome de détresse respiratoire aiguë

It is now well established that prone position (PP) sessions can improve arterial oxygenation in the majority of patients with acute hypoxemic respiratory failure. The underlying mechanism of this beneficial response is not completely understood but is likely due to the alveolar recruitment of the dependent lung units which are atelectatic in supine position and remain still perfused in prone position. Some animal studies suggest that PP could reduce the extent of lung damage resulting from high tidal volumes applied during mechanical ventilation, and can increase the efficiency of recruitment manoeuvres, like sustained inflation, at lower levels of positive-end expiratory pressure. Optimal prone positioning is relatively easy to perform without any specific additional equipment. It requires, however, trained and motivated medical and nursing staff and an available written procedure. The impressive complications observed in the early days, such as endotracheal tube or central venous lines removal while changing positions, no longer occur. The overpressure-induced skin lesions can be significantly reduced by following precise recommendations. Some questions are still not resolved in the clinical practice, such as: when should PP be started from the onset of mechanical ventilation? Probably as early as possible. What should be the optimal duration of the PP session? For how long should we continue PP in a responder patient? One important issue, namely the impact of PP on patient outcome, is being tested in randomized control trials, which are ongoing in three European countries.     

Syndrome de détresse respiratoire aiguë

Nutrients and nutrition may alter the inflammatory response during acute respiratory distress syndrome. Early enteral nutrition is a major challenge requiring to be delivered based on protocols to reduce gastrointestinal side-effects. However, the role of immunonutriments remains debated. Nutritional support should be prolonged after weaning from mechanical ventilation and discharge from the intensive care unit.     

Intoxication aiguë au monoxyde de carbone et séquelles neurologiques : de la physiologie à la clinique

Neuropsychiatric sequelae of carbon monoxide (CO) poisoning occur in up to 50% of all patients presenting with toxic CO levels. Neurological abnormalities include persistent (PNS) and delayed neurological sequelae (DNS) that occur after an asymptomatic period. Multiple hypotheses explain the mechanisms by which CO toxicity leads to cerebral injury including prolonged hypoxemia and dysfunction of intracellular mitochondrial cytochrome oxydase. Neurological examination shows impairments in memory and concentration as well as parkinsonism. Urinary and fecal incontinences represent common problems in severely CO-poisoned patients. No neuroprotective agents have yet demonstrated efficacy in preventing or improving delayed post-anoxic encephalopathy. Data on the effects of hyperbaric oxygen are conflicting because of the absence of any consensual protocol to treat CO poisonings.     

Résultats de l’assistance respiratoire extracorporelle dans les syndromes de détresse respiratoire aiguë sévères

Major technological improvements in extracorporeal membrane oxygenation (ECMO) machines and the positive results of the CESAR trial have reignited the interest for veno-venous (VV)-ECMO in patients with severe acute respiratory distress syndrome (ARDS) and persistent hypoxemia or hypercarbia on conventional mechanical ventilation. The technique has also been successfully used for the most severe ARDS cases associated with the recent Influenza A(H1N1) pandemic. However, since the CESAR study was criticized for methodological limitations and because results of non-randomized case-series of ECMO are prone to selection biases, indications for VV-ECMO use remain highly controversial. Before widespread diffusion of VV-ECMO for severe ARDS, new trials should test the efficacy of early initiation of the technique with tight control of mechanical ventilation in the control group, initiation of ECMO prior to transportation to ECMO centers, and the use of ECMO in every patient randomly assigned to receive it.     

Ventilation liquide partielle dans le syndrome de détresse respiratoire aiguë

Partial liquid ventilation has known considerable development in both the experimental and the clinical fields of acute respiratory distress syndrome. This was due to the unique properties of perfluorocarbons that enable gas exchange enhancement and pulmonary mechanics restoration by acting as liquid-PEEP and surfactant.Current developments and highlights. – Recent experimental studies have paradoxically underlined both the dose-dependent improvement of gas exchanges during partial liquid ventilation and the increased risk of baro- and volutrauma with the use of high doses of perfluorocarbon and high levels of PEEP. Results from a recent international multicenter randomized controlled study have recently illustrated such risks. In this study, partial liquid ventilation had no beneficial effects in terms of mortality but was associated with a higher risk of barotrauma.New horizons and prospects. – These disappointing results have stimulated research on liquid ventilation in both new modalities of perfluorocarbon administration such as aerosol and new fields such as intrapulmonary drug delivery.