Is endoscopic sphincterotomy for disabling biliary-type pain after cholecystectomy effective?

Between 1979 and 1983, 50 patients were treated by endoscopic sphincterotomy for disabling biliary-type pain after cholecystectomy. Forty-six patients were seen at regular intervals for at least 12 months after the procedure and of these, pain resolved in six (13%), decreased in severity and/or frequency in 22 (48%), and continued unchanged in 18 (39%). Patients with bile duct dilation on a retrograde cholangiogram had a similar outcome to those with a bile duct of normal caliber. Twenty-five patients had a morphine-neostigmine test and endoscopic manometry of the sphincter of Oddi prior to the procedure, and the outcome appeared to be independent of results from these investigations. Subgroups of patients who benefit from sphincterotomy will be determined only by prospective studies in which criteria for inclusion are carefully defined so as to avoid heterogeneity within study groups.     

Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction

BACKGROUND—Endoscopic sphincterotomy for biliary-type pain after cholecystectomy remains controversial despite evidence of efficacy in some patients with a high sphincter of Oddi (SO) basal pressure (SO stenosis).
AIM—To evaluate the effects of sphincterotomy in patients randomised on the basis of results from endoscopic biliary manometry.
METHODS—Endoscopic biliary manometry was performed in 81 patients with biliary-type pain after cholecystectomy who had a dilated bile duct on retrograde cholangiography, transient increases in liver enzymes after episodes of pain, or positive responses to challenge with morphine/neostigmine. The manometric record was categorised as SO stenosis, SO dyskinesia, or normal, after which the patient was randomised in each category to sphincterotomy or to a sham procedure in a prospective double blind study. Symptoms were assessed at intervals of three months for 24 months by an independent observer, and the effects of sphincterotomy on sphincter function were monitored by repeat manometry after three and 24 months.
RESULTS—In the SO stenosis group, symptoms improved in 11 of 13 patients treated by sphincterotomy and in five of 13 subjected to a sham procedure (p = 0.041). When manometric records were categorised as dyskinesia or normal, results from sphincterotomy and sham procedures did not differ. Complications were rare, but included mild pancreatitis in seven patients (14 episodes) and a collection in the right upper quadrant, presumably related to a minor perforation. At three months, the endoscopic incision was extended in 19 patients because of manometric evidence of incomplete division of the sphincter.
CONCLUSION—In patients with presumed SO dysfunction, endoscopic sphincterotomy is helpful in those with manometric features of SO stenosis.


Keywords: sphincter of Oddi; manometry; endoscopic sphincterotomy; motility; bile duct; pancreas     

South Australian Scleroderma Register: autoantibodies as predictive biomarkers of phenotype and outcome

Aim: To investigate the relationship between scleroderma‐specific autoantibodies and clinical phenotype and survival in South Australian patients with scleroderma. Method: Two cohorts of patients were studied from the South Australian Scleroderma Register (SASR). In the first, the sera of 129 consecutive patients were analyzed for anticentromere (ACA), anti‐Scl70, anti‐RNA polymerase III, anti‐U1RNP, anti‐Th/To, anti‐Pm/Scl, anti‐Ku and anti‐fibrillarin antibodies using the Euroline immunoblot assay. Statistical analysis was performed to look for a significant association between specific antibodies and various clinical features. In the second cohort survival from first symptom onset was analyzed in 285 patients in whom the autoantibody profile was available, including ACA, Anti‐Scl70, anti‐U1RNP and anti‐RNA polymerase III measured using multiple methods. Survival analysis compared mortality between different groups of patients with specific antibodies. Results: ACA, Th/To and Ku antibodies were associated with limited scleroderma, Scl70 and RNA Pol III antibodies were associated with diffuse scleroderma and antibodies to U1RNP were associated with overlap syndrome. Significant associations between Scl70 and interstitial lung disease (P = 0.004), RNA Pol III and renal crisis (P = 0.002), U1RNP and pulmonary hypertension (P = 0.006) and Th/To and pulmonary hypertension (P = 0.034) were seen. Trends were observed with an increased frequency of lung disease with Pm/Scl and Th/To and an increased frequency of myositis with Ku. The presence of Scl70, RNA Pol III and U1RNP was associated with significantly reduced survival as compared with patients with ACA. Conclusions: Scleroderma‐specific autoantibodies are associated with clinical phenotype and survival.     

Factors relating to circulating immune complexes in rheumatoid arthirits.

Evidence has been presented suggesting that circulating immune complexes occur in over half of the sera of patients with rheumatoid arthritis. These IgG-containing complexes were small, eluting between IgG and IgM on gel filtration on Sepharose 6B and were not seen in the sera of healthy control subjects. These complexes were detected in the sera of both seronegative and seropositive patients and their quantity did not correlate with IgM rheumatoid factor titre. The quantity of complexed IgG was estimated from a ratio derived from the IgG profile obtained by gel filtration of the serum. This quantity correlated significantly with the degree of inhibition by the rheumatoid sera of cytolysis in vitro of IgG sensitized target cells by K cells from human peripheral blood. A significant inverse correlation was observed between the quantity of serum complexes and the chemotactic index of the circulating polymorphonuclear leucocytes obtained from the same rheumatoid patient. It is suggested that ingestion of these complexes may be implicated in the reduction in chemotaxis observed in patients with rheumatoid arthritis. There was no correlation between the quantity of the complexes in the sera and the clinica, haematological, and biochemical measurements.     

Prevalence of sicca symptoms in a South Australian cohort with systemic sclerosis

Background: The presence of sicca symptoms is a frequent finding in patients with systemic sclerosis (SSc). The aim of this study was to examine the prevalence of sicca symptoms in a South Australian cohort of SSc patients and correlate this to a number of parameters, including autoantibody status, use of anticholinergic medication, age and the presence of functional anti‐muscarinic‐3 receptor (M3R)‐blocking antibodies. Methods: A screening questionnaire was sent out to all patients on the South Australian Scleroderma Register from the years 1998–2006 to determine the prevalence of sicca symptoms. A subset of patients on the register had ocular sicca symptoms tested by use of Schirmer’s strips to validate the accuracy of the questionnaire. Eight patients were tested for anti‐M3R‐blocking antibodies using a functional physiological assay. Results: One hundred and ninety‐three SSc patients took part in this study. Sicca symptoms were present in 59% of patients with the limited form of SSc, compared with 49% of patients with the diffuse form and 40% of patients with the overlap syndrome. The use of anticholinergic medication or thyroxine was associated with higher sicca scores in SSc patients. SS‐A and SS‐B autoantibodies (seen in Sjögren’s syndrome) were detected in eight patients in this study. The detection of anti‐M3R‐blocking antibodies correlated well to presence of sicca. Conclusion: This study confirmed that sicca symptoms are found in a high proportion of patients with SSc, especially those with the limited variant. Further testing of larger numbers of SSc patients with sicca for anti‐M3R‐blocking antibodies will be needed before more definitive conclusions can be drawn. Physicians should be made aware that sicca symptoms are a frequent cause of morbidity for SSc patients * .     

A study of scleroderma in South Australia: prevalence, subset characteristics and nailfold capillaroscopy

Background: Scleroderma is a systemic rheumatic disorder seen in a wide range of clinical specialties. Aims: To establish the prevalence and mortality rates of scleroderma in South Australia (SA), to determine the relative frequency and characteristics of the three principal subsets (diffuse, limited and overlap), and to examine the role of nailfold capillaroscopy in subset identification and implied prognosis. Methods: Outpatient and discharge diagnostic indexes from five major teaching hospitals in SA were reviewed between February 1987 and November 1993. A total of 215 patients with scleroderma were identified. Case notes of 115 of these patients were reviewed in order to validate scleroderma diagnosis, and subset characteristics such as sex, mean age at diagnosis, extent of skin involvement, internal organ involvement and serology were analysed. Fifty-two of these patients were then examined prospectively to confirm positive discharge diagnosis, and nailfold capillaroscopy was performed on these patients. Results: The point prevalence of scleroderma in SA for 1993 was estimated to be 208/10⁶. This figure is a conservative estimate and is higher than most other reported series. The female to male ratio was 4:1. The majority of patients had limited disease with a ratio of 6:1:1.6 limited vs diffuse vs overlap. Systemic involvement excluding the oesophageal component in limited disease was found predominantly in the diffuse group. Autoimmune serology was positive in 90% of patients, with Scl-70 being more common in diffuse scleroderma, anti-centromere antibody (ACA) in the limited form and anti-ribonucleoprotein (RNP) in the overlap form. Nailfold capillaroscopy was useful in predicting disease-subtype as capillary dilatation was observed predominantly in limited disease, and capillary dropout in diffuse disease. Conclusions: Scleroderma is more common in SA than previously recognised. Limited disease is more common than diffuse or overlap disease, carries a better prognosis and is associated with ACA. Nailfold capillaroscopy is a useful tool in disease assessment and may provide useful diagnostic and prognostic information.     

A randomized placebo-controlled trial of arthroscopic lavage versus lavage plus intra-articular corticosteroids in the management of symptomatic osteoarthritis of the knee

OBJECTIVE: To assess the efficacy of intra-articular steroid injections following arthroscopy and joint lavage in symptomatic OA of the knee. METHODS: Seventy-seven patients with OA of the knee were randomized to receive either 120 mg methylprednisolone acetate (MPA) or placebo following arthroscopy. Clinical assessments included severity of pain on movement and at rest, stiffness, the presence of joint effusions, range of movement, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score and Lequesne functional assessment. The outcome measures were evaluated at baseline and 2, 4, 8, 12 and 24 weeks. Further arthroscopies and synovial biopsies were performed at the time of clinical response and at relapse. RESULTS: An intention-to-treat analysis was performed on 71 patients (38 MPA, 33 placebo). Using the OARSI (Osteoarthritis Research Society International) response criteria, 58% of the steroid group vs 33% of the placebo group (adjusted relative risk = 2.38) (P = 0.004) responded at 4 weeks. At other time points, there were no significant differences between the treatment groups. There were no significant differences between the two treatment groups for pain, stiffness or WOMAC or Lequesne assessments at any time point. CONCLUSIONS: The response to intra-articular corticosteroids following joint lavage is short-lived (2-4 weeks), achievement of an OARSI response criterion being the only difference between the two groups.