Choledochoduodenal fistula at the anterior wall of the duodenal bulb: a rare complication of duodenal ulcer

A 38 year-old man was admitted to our hospital with the chief complaint of epigastralgia. His laboratory data revealed leukocytosis and increased serum amylase, and abdominal ultrasonography revealed diffuse swelling of the pancreas. Thus, he was diagnosed as having acute pancreatitis. Moreover, abdominal computed tomography showed pneumobilia in the gallbladder and the common bile duct. Gastroduodenal fiberscopy demonstrated peptic ulcer scars around a foramen with smooth margins at the anterior wall of the duodenal bulb. The bile juice flowed from the bottom of the foramen. Endoscopic retrograde cholangiopancreatography revealed the fistula between the common bile duct and the anterior wall of the duodenal bulb, but not the posterior wall. However, there was no pancreatico-biliary maljunction and no stones in the gallbladder or bile duct. This is a rare case of choledochoduodenal fistula at the anterior wall of the duodenal bulb caused by duodenal peptic ulcer disease.     

Clinical Effectiveness of Tolvaptan in Patients with Acute Decompensated Heart Failure and Renal Failure: Design and Rationale of the AQUAMARINE Study

Purpose

Over half of all admitted acute decompensated heart failure (ADHF) patients have renal failure. Although diuretics represent the mainstay of treatment strategy even in this population, there are unmet needs for safer and more effective treatment. Tolvaptan is a vasopressin-2 receptor antagonist, and we hypothesized that adding tolvaptan to standard diuretic therapy would be more effective in ADHF patients with renal function impairment.

Methods

The Answering question on tolvaptan’s efficacy for patients with acute decompensated heart failure and renal failure (AQUAMARINE) is a multicenter, randomized controlled clinical trial, which will enroll 220 patients from 17 hospitals in Japan. ADHF patients whose estimated glomerular filtration rate is above 15 and below 60 mL/min/1.72 m² will be randomly assigned within 6 h after admission to usual care with furosemide or tolvaptan add-on therapy. Primary endpoint is achieved urine output within 48 h. Secondary endpoints include dyspnea relief measured by 7-points Likert scale, incidence of worsening renal function, dose of furosemide used within 48 h, and changes of brain natriuretic peptide.

Conclusion

This study is the first multicenter study in Japan to evaluate clinical effectiveness of tolvaptan add-on therapy in ADHF patients with renal failure. The results of this study address the treatment strategy of this high-risk population (UMIN Clinical Trial Registry Number: UMIN000007109).     

Incidence of Urolithiasis in Northeast Thailand

Background :
Urolithiasis is a major health problem in the northeast part of Thailand. In this study, we examined the prevalence of renal stone disease and differences of urinary components between stone formers and healthy control subjects in northeastern rural areas of Thailand.
Methods :
We selected 3 villages in the rural areas of Khon Kaen province in northeast Thailand. Three hundred and sixty-seven persons were asked questions relating to urolithiasis and were examined by abdominal ultrasound (US). We collected a spot urine sample from stone formers and healthy control subjects from each village.
Results :
Abnormal findings by US were detected in 39 individuals (10.6%), and included 31 individuals with renal calculi (8.4%), 16 with hydronephrosis (4.4%), and 1 individual with a renal cyst (0.3%). This yielded a disease rate of urinary stones in this study of 16.9%. The male/female ratio was 2/1 and the average age of the individuals examined was 40.3 + 13.9 years. However, there was no significant difference between the urinary parameters of stone formers and the healthy control subjects. Conclusion: There was a high incidence of renal stone disease in the northeast part of Thailand, but the tendency for hypocitraturia was only found in stone formers.     

Ketoacidosis,Hypertriglyceridemia and Acute Pancreatitis Induced by Soft Drink Polydipsia in a Patient with Occult Central Diabetes Insipidus

A 21-year-old Japanese man without known diabetes mellitus had abdominal pain. The diagnosis was ketoacidosis and hypertriglyceridemia-induced acute pancreatitis. He had polydipsia and polyuria and had habitually drunk several soft drinks every day for two years. After hospitalization, despite adequate liquid intake, dehydration remained with hypotonic polyuria. Further examinations revealed the coexistence of central diabetes insipidus (CDI), possibly caused by lymphocytic infundibulo-neurohypophysitis, based on anti-rabphilin-3A antibody positivity. Although CDI had been undiagnosed for two years, over-consumption of sugar-rich soft drinks to ease thirst caused ketoacidosis, hypertriglyceridemia, and acute pancreatitis. There are no previous reports of this three-part combination of symptoms caused by CDI.     

The diagnostic value of dual-phase cone-beam CT during hepatic arteriography in transarterial chemoembolization for hepatocellular carcinoma

To evaluate the diagnostic value of dual-phase cone beam CT during hepatic arteriography (CBCTHA) for hepatocellular carcinoma (HCC).Thirty seven patients with unresectable HCC underwent the dual-phase CBCTHA prior to transarterial chemoembolization (TACE). Three blinded observers independently reviewed and compared the first phase CBCTHA images alone and the dual phase CBCTHA images. Diagnostic accuracy was evaluated by the alternative free-response receiver operating characteristic method (Area under the curve: Az value). Sensitivities were analyzed with the paired t test. The analysis was performed for overall HCCs, HCCs up to 1 cm and those larger than 1 cm.For all HCCs and HCCs up to 1 cm, Az value and sensitivity showed no significant difference between the first-phase CBCTHA alone and the dual-phase CBCTHA (Az: 0.81 vs 0.88, P = .07, 0.79 and 0.85, P = .14, sensitivity: 0.61 and 0.73, P = .11, 0.41 and 0.52, P = .33, respectively). For HCCs larger than 1 cm, the mean Az value and sensitivity for the dual-phase CBCTHA were significantly higher than those for the first phase CBCTHA alone (Az: 0.96 vs 0.92, P = .008, sensitivity: 0.85 vs 0.75, P = .013, respectively).The diagnostic accuracy of the dual-phase CBCTHA was superior to that of the first phase CBCTHA alone in the diagnosis of HCC larger than 1 cm.     

Translation,validation and cultural adaptation of “The Eustachian Tube Dysfunction Questionnaire-7” (ETDQ-7) to Brazilian Portuguese (BR)

IntroductionChronic Eustachian tube dysfunction can cause several symptoms and middle ear conditions that can impact patient quality of life. It is estimated to be relatively frequent, affecting approximately 5% of adults. The diagnostic tools for this condition are still inadequate. In 2012, McCoul et al. published a questionnaire for the evaluation of Eustachian tube dysfunction named ETDQ-7. They established its replicability and validity. The cutoff point for the diagnosis of chronic Eustachian tube dysfunction was equal to or greater than 14.5, with 100% sensitivity and 100% specificity.ObjectiveTo translate, adapt and validate the ETDQ-7 questionnaire to Brazilian Portuguese.MethodsWe translated the questionnaire into Brazilian Portuguese and applied it to 50 patients, 20 of whom had chronic Eustachian tube dysfunction, and 30 controls.ResultsThe results obtained with the North-American questionnaire were confirmed in its Brazilian version. The cut-off point for the diagnosis of chronic Eustachian tube dysfunction was ≥14, also exhibiting high sensitivity and specificity, very similar to that of ETDQ-7.ConclusionIt is recommended that ETDQ-7 be used to complement the clinical history of patients with chronic Eustachian tube dysfunction; it can also be used as an important tool for diagnosis, patient follow-up and treatment management.     

Significance of occipitoaxial angle in subaxial lesion after occipitocervical fusion

STUDY DESIGN: The significance of occipitoaxial angle in the development of subaxial subluxation after occipitocervical fusion was determined in a minimum 5-year follow-up study performed retrospectively. OBJECTIVE: To clarify the association between the position of the fixed occipital bone and axis and the development of subaxial subluxation. SUMMARY OF BACKGROUND DATA: There have been few reports describing the association between the position of fixation of the occipital bone and axis and subaxial lesion in occipitocervical fusion. MATERIALS AND METHODS: Thirty-eight patients with rheumatoid arthritis who underwent occipitocervical fusion for irreducible atlantoaxial dislocation were reviewed. The angle between the McGregor line and the inferior surface of the axis (O-C2) was measured in healthy volunteers and patients who had undergone occipitocervical fusion. The association between any changes in the alignment of the cervical vertebrae and the development of subaxial subluxation during follow-up periods was studied. RESULTS: The number of the patients in whom postoperative kyphosis and swan neck deformity developed was only five, but in four (80%) of them, retroversion of the occipital bone was used to increase the O-C2 angle. In 14 patients, in whom anteversion of the occipital bone against the axis was excessive, 12 (86%) patients experienced subaxial subluxation after surgery. In the patients in whom fixed O-C2 angles were in normal range, only one patient developed such abnormal changes in the middle and lower cervical vertebrae. CONCLUSION: It is necessary to give attention to the position of the fixed occipital bone and axis during procedures of occipitoaxial fusion for patients with rheumatoid arthritis.     

The Evaluation of Duct-to-mucosal Pancreaticojejunostomy in pancreaticoduodenectomy

This study was conducted to examine the efficacy of duct-to-mucosal pancreaticojejunostomy compared with external stented pancreaticojejunostomy in prevention of several complications, retrospectively. Seventy-six patients with pancreatic head resection (59 male; median age, 60.1 years) underwent pancreaticoduodenectomy at the Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan, between January 1, 1994, and March 31, 2002. In early postoperative status, the incidence of pancreatic fistula by duct-to-mucosal anastomosis (n = 45) was similar to that by external stent (n = 31); soft pancreas is a risk factor of pancreatic fistula compared with hard pancreas (p < 0.05). During the late postoperative period, however, no patients with duct-to-mucosal anastomosis showed pancreatic duct dilatation by computed tomography (CT). At the same time, 58.8% of patients with external stent followed by CT showed pancreatic duct dilatation (p < 0.01). The duct-to-mucosal anastomosis was more effective pancreaticojejunostomy than the external stent in terms of prevention of pancreatic duct dilatation, and it should be the surgical procedure of choice in pancreaticoduodenectomy.