A Rare Case of Biliobiliary Fistula

Abstract: Biliobiliary fistula is a rare clinical entity. The case of a 72 year old female, who presented with epigastric pain and jaundice, is detailed herein. Endoscopic retrograde cholangiopancreatography (ERCP) revealed two stones, one each in the common bile duct and the gallbladder. Continuous endoscopic nasobiliary drainage (ENBD) was performed to relieve obstructive jaundice. Further study with contrast medium administered via the ENBD tube revealed a fistula between the neck of the gallbladder and the common bile duct. The cystic duct was intact. A stone was considered to have migrated into the common bile duct through the fistula. A diagnosis of biliobiliary fistula, Corlette type I was made. However, in this particular case, a biliobiliary fistula was noted at a site below the junction of the cystic duct and common bile duct. Removal of the gallbladder stones was followed by cholecystectomy. The common bile duct was then repaired by utilizing a T-tube. No evidence of malignancy was recognized in the resected gallbladder specimen. In the one year to date since surgery, the patient has been asymptomatic and without signs of biliary disease.     

Clinical features of childhood-onset schizophrenia with obsessive-compulsive symptoms during the prodromal phase

Abstract Thirty-nine patients with schizophrenia, diagnosed according to DSM-III-R, who were under 15 years of age, were studied in two groups; 16 subjects with obsessive-compulsive symptoms during the prodromal phase, and 23 with no obsessive-compulsive disorders. The group with obsessive-compulsive symptoms during the prodromal phase was characterized by a higher ratio of males, higher incidences of perinatal and brain computed tomography (CT) abnormalities, fewer hereditary factors, longer duration of the prodromal phase, and a higher incidence of insidious onset and negative symptoms compared with the group without such prodromal symptoms. Schizophrenic patients with obsessive-compulsive symptoms during the prodromal phase were clinically distinct from those without, which suggests the possibility of subtype categorization.     

Relationship between severity and symptoms of reflux oesophagitis in elderly patients in Japan

Since information concerning reflux oesophagitis in the elderly is limited, particularly in Japan, the severity and symptomatic profiles of reflux oesophagitis in elderly patients were investigated. One hundred and nineteen patients with reflux oesophagitis found among 2278 endoscopy cases between 1993 and 1996 were investigated in this study. The patients were divided into two groups, elderly and non-elderly. The severity of reflux oesophagitis was estimated by the Los Angeles classification. The presence or absence of typical symptoms (heartburn and regurgitation) was determined by interview. Reflux oesophagitis was not only more frequently found in the elderly group, but was more severe than in the non-elderly. Although the degree of manifestation of typical symptoms was similar between the elderly and the non-elderly with high-grade oesophagitis, the elderly patients with mild reflux oesophagitis were less symptomatic than the non-elderly. Mild reflux oesophagitis in the elderly may be missed due to its rarity of typical reflux symptoms and a substantial number of elderly persons might have subclinical reflux oesophagitis.     

Effects of glycyrrhizin on immune-mediated cytotoxicity

Intravenous administration of glycyrrhizin is known to decrease elevated plasma transaminase levels in patients with chronic viral hepatitis, in which immune-mediated cytotoxicity by cytotoxic T lymphocytes and tumour necrosis factor (TNF)-α is considered to play an important pathogenic role. However, the immunological interpretation of the transaminase-lowering action of glycyrrhizin is not known. Studies were performed to elucidate this action immunologically by assessing the effects of glycyrrhizin on immune-mediated cytotoxicity using an antigen-specific murine CD4⁺ T hybridoma line, which exhibits cytotoxicity against antigen-presenting cells after stimulation with specific antigen, and a murine TNF-α-sensitive fibroblast line. Glycyrrhizin inhibited the cytotoxic activity of the T cells against antigen-presenting cells and also suppressed TNF-α-induced cytotoxicity in the TNF-α-sensitive cell line in vitro. These results suggest that the decrease of elevated transaminase levels by glycyrrhizin in patients with chronic viral hepatitis is mediated in part by inhibition of immune-mediated cytotoxicity against hepatocytes.     

Case of cutaneous malignant melanoma surviving 16 years with late recurrence

Late recurrence, defined as that occurring 10 or more years after diagnosis, is an unusual event in cutaneous malignant melanoma (MM). A 59-year-old woman presented with a black nodule measuring 10 mm × 9 mm on the sole of her right foot. She was diagnosed with MM and the tumor was totally excised with 5 cm of the normal surrounding skin. Eleven years after the operation, five in-transit metastases were found in her right limb. They were all excised and β-interferon (IFN-β) was injected into the skin around the postoperative scars. However, numerous new in-transit skin metastases have been emerging every year in her right limb. Fifty-four in-transit skin metastases have so far been found. Recently, there have been few in-transit metastases. All in-transit metastatic lesions were excised and local IFN-β injections were conducted continuously. There is no evidence of metastases to the internal organs or lymph nodes. This report describes this case with a brief review of the published work concerning the rare late recurrences of MM.     

Determinant of QT Dispersion in Patients with Hypertrophic Cardiomyopathy

KAWASAKI, T., et al. : Determinant of QT Dispersion in Patients with Hypertrophic Cardiomyopathy. QT dispersion is thought to reflect a regional difference in repolarization process although QT interval is composed of depolarization and repolarization. This study was designed to investigate the effect of depolarization and repolarization on QT dispersion in hypertrophic cardiomyopathy. Standard 12-lead ECG was recorded in 70 hypertrophic cardiomyopathy patients with anteroseptal wall hypertrophy (HC-As), 8 patients with lateral wall hypertrophy (HC-L), 8 patients with diffuse hypertrophy (HC-D), and 46 normal controls. QRS, JTc, maximum and minimum QTc, and QTc dispersion were compared. The maximum QTc was greater in HC-As and HC-L than in the control; the minimum QTc was similar in all 3 groups; consequently, QTc dispersion was greater in HC-As and HC-L. In HC-D, the maximum QTc and the minimum QTc were greater than the control, which produced QTc dispersion similar to that in the control. JTc did not differ among 4 groups. In hypertrophic cardiomyopathy, both QTc and QRS duration were increased in the leads coinciding with the left ventricular portion of localized hypertrophy. We conclude that QTc dispersion depended on the heterogeneity of QRS duration or depolarization rather than repolarization, which in fact may be ascribed to the regionally different hypertrophy of the left ventricle in hypertrophic cardiomyopathy. (PACE 2003; 26[Pt. I]:819–826)     

Clinical and Electrophysiological Difference Between Idiopathic Right Ventricular Outflow Tract Arrhythmias and Pulmonary Artery Arrhythmias

Characteristics of Pulmonary Artery Arrhythmias. Introduction: The precise incidence and characteristics of ventricular arrhythmias originating from the pulmonary artery have not been fully described. The purpose of this prospective study was to clarify these points. Methods: Thirty‐three consecutive patients with an idiopathic left bundle branch block and inferior‐axis deviation type ventricular arrhythmia were included. All patients underwent detailed electroanatomical mapping (CARTO, Biosense‐Webster, Diamond Bar, CA, USA) during sinus rhythm prior to the catheter ablation. The precise location of the catheter tip at the successful ablation site was confirmed by both electroanatomical mapping and contrast radiography. The clinical and electrophysiological data were compared between the right ventricular outflow tract (RVOT) arrhythmia patients (RVOT group) and PA arrhythmia patients (PA group). Results: Eight patients (8/33 patients: 24.2%) had their ventricular arrhythmias successfully ablated within the PA. The local bipolar electrogram at the successful ablation sites in the PA group exhibited a significantly greater duration (P < 0.05) and lower amplitude (P < 0.05) than did those in the RVOT group (n = 19). In the PA group, all patients exhibited a multicomponent electrograms composed of a spiky potential and a dull potential, which might have consisted of near‐field PA activation and a far‐field ventricular activation, respectively, at the successful ablation site. Direct ablation to the spiky electrogram was able to eliminate the arrhythmias in all the PA group patients. Conclusions: PA arrhythmias may be more common than previously recognized. Careful mapping and interpretation of low amplitude and multicomponent electrograms are important for recognizing ventricular arrhythmias originating from the PA. (J Cardiovasc Electrophysiol, Vol. 21, pp. 163‐169, February 2010)     

Challenging behavior of patients with frontal dysfunction managed successfully with behavioral intervention

Herein, we report on two clinical cases in which behavioral disturbances occurred due to frontal dysfunction. Both patients were treated successfully with behavioral intervention. In the first case, the patient's challenging behavior of repeatedly entering his wife's workplace and interrupting her work was reduced after the patient's wife changed her response to the behavior and her schedule prior to work to ensure that she spent time with him in the morning. In the second case, the patient's challenging behavior of urinating in the street was reduced by changing his walking route. The successful outcome in both cases suggests that behavioral intervention based on Antecedents, Behavior, and Consequences (ABC) analysis is useful in the management of behavioral disturbance due to frontal dysfunction.