Cholecystocolic fistula: an unusual presentation and diagnosis by endoscopic retrograde cholangiopancreatography

Summary This report describes a patient with a cholecystocolic fistula whose presentation was unusual because it lacked the signs and symptoms that suggest biliary disease (abdominal pain, food intolerance, and belching) and because the fistula was not visualized on barium enema but was apparent on endoscopic retrograde cholangiopancreatography after incidental pneumobilia discovered on ultrasound directed our attention to the biliary tree. A previous Billroth II with vagotomy may have predisposed to the development of the fistula.     

The small intestine in diabetes mellitus. Correlation of clinical phenomena to histomorphometric findings in peroral biopsy material

Summary Biopsy material obtained from the first portion of the jejunum of 56 unselected diabetics and 21 normal controls was examined under the electron microscope (in 8 cases) or with a method of stereologic morphometry. Controls were found to have a villous volume (VVi) of 50.19±10.1%. All values below 40% were interpreted as an expression of deterioration of the mucous membrane. Altogether 12.5% of the diabetics showed total atrophy, and 20% had significant reduction of VVi. These changes did not correlate with intestinal disorders or other signs of diabetes. In total atrophy histochemical changes could be demonstrated. Microangiopathy was not observed in the intestinal mucosa.     

25-Hydroxy vitamin D absorption test in patients with gastrointestinal disorders

Summary To evaluate the relationships of a 25-hydroxy vitamin D absorption test to intestinal fat absorption and to the absorption of radioactively labeled vitamin D and 25-hydroxy vitamin D, an investigation was undertaken in 19 patients with gastrointestinal disorders. A correlation was noted between the results of the 25-hydroxy vitamin D absorption test and baseline 25-hydroxy vitamin D levels. No correlation was found between results of the 25-hydroxy vitamin D absorption test and quantitative fecal fat excretion. Peak values of the 25-hydroxy vitamin D absorption test correlated with net absorption of¹⁴C vitamin D. No correlation existed between the values obtained in the 25-hydroxy vitamin D absorption test and³H-25-OH D absorption. These studies indicate that the 25-hydroxy vitamin D absorption test probably does not serve as an effective screening test for intestinal fat malabsorption. The results of the test probably most accurately reflect the body stores of vitamin D at the time of testing, but there appears to be little advantage to performing a 25-hydroxy vitamin D absorption test in lieu of a single determination of the serum level of 25-hydroxy vitamin D as a method of evaluating vitamin D nutritional status.     

Prevalence of antibodies toYersinia enterocolitica O:3 among Norwegian military recruits: Association with risk factors and clinical manifestations

IgG antibody activity toYersinia enterocolitica serogroup O:3 was detected in sera from 56 (7.4%) of 755 Norwegian military recruits, using an enzyme-linked immunosorbent assay. The highest prevalence was found among recruits from Oslo city (12/56, 21.4%). The recruits answered a questionnaire which covered demographic data, specific exposures, and clinical information. The following risk factors were found to be independently associated with IgG activity in logistic regression analysis: receiving drinking water from a private well (odds ratio (OR)=3.40;p=0.004), being a resident of Oslo city (OR=2.99;p=0.006), and living in eastern Norway (OR=2.25;p=0.015). By univariate analysis, living in an urban area was associated with IgG activity, but this factor did not independently affect risk. Present or previous contact with animals, including pigs, and travels abroad were not associated with an increased risk.Yersinia enterocolitica O:3 seropositive recruits were more likely to report previous surgery for suspected appendicitis than seronegative individuals (OR=4.26;p=0.0024). Among recruits with previous appendectomy, mesenteric lymphadenitis as the sole peroperative finding was more common in patients with IgG activity to Y. enterocolitica O:3 (4/7) than in seronegative patients (1/19) (p=0.01). Recurrent diarrhea, steatorrhea or joint complaints were not associated with antibody activity.     

Conduite à tenir pratique pour l’exploration d’une malabsorption,d’une maldigestion,et d’une entéropathie exsudative

Malabsorption syndrome can be suspected in situations ranging from isolated deficiencies to the classic association between abundant chronic diarrhea and weight loss. Pitfalls in diagnosis come from the multiplicity of pathophysiological mechanisms. Malabsorption can happen in the gut lumen (maldigestion), the intestinal wall, or involve transporters beyond the enterocyte. The challenge is in the diagnostic process, which requires a thorough questioning and physical examination, conducting laboratory tests, endoscopy and imaging studies to confirm malabsorption and find its etiology so as to provide the best treatment.     

Predisposing Factors for Nephrolithiasis and Nephrocalcinosis in Cystic Fibrosis

Objective

Cystic fibrosis (CF) is characterized by chronic pulmonary disease, insufficient pancreatic and digestive function, and abnormal sweat concentration. There is controversy about predisposing factors of nephrolithiasis and nephrocalcinosis in patients with cystic fibrosis. We assessed the results of metabolic evaluation in patients with cystic fibrosis and its correlation with nephrocalcinosis.

Methods

Forty five CF patients, mean age 47.1 months, were enrolled in the study. No one had past history of nephrolithiasis and/or nephrocalcinosis. The records were reviewed for clinical characteristics and all patients underwent metabolic evaluation including serum electrolyte measurements and spot urine analysis. Ultrasonography was performed in all patients to detect nephrocalcinosis and urolithiasis.

Findings

Nephrocalcinosis was found in 5 (11%) patients. No patient had clinical symptoms of nephrolithiasis and/or micro/macroscopic hematuria. Metabolic evaluation of the CF patients versus normal reference values showed decreased serum uric acid in 48.8%, elevated serum phosphate in 24.4%, and urine oxalate excretion in 51%. Metabolic evaluation of the nephrocalcinosis positive patients versus nephrocalcinosis negative group showed no statistical difference in serum electrolytes. The mean value of urine calcium excretion was lower in patients with nephrocalcinosis (P=0.001). Despite lack of any significant correlation, higher numerical hyperoxaluria was observed in patients with severe steatorrhea. There was no statistical correlation between steatorrhea and urine calcium as well as oxalate excretion.

Conclusion

Hypocalciuria in the nephrocalcinotic CF patients may be seen. It can be hypothesized that hypocalciuria may be due to a primary defect in renal calcium metabolism in CF patients.     

Natural course of chronic pancreatitis and predictors of its progression

BackgroundThe natural course of chronic pancreatitis(CP) and its complications has been inadequately explored. We aimed to describe the natural history and factors affecting the progression of alcoholic(ACP), idiopathic juvenile(IJCP) and idiopathic senile(ISCP) variants of CP.MethodsThis study was a retrospective analysis from a prospectively maintained database of patients with CP following up at a tertiary care centre from 1998 to 2019. Cumulative rates of pain resolution, diabetes, steatorrhea, pseudocysts and pancreatic cancer were computed using Kaplan-Meier analysis, and the factors affecting their incidence were identified on multivariable-adjusted Cox-proportional-hazards model.ResultsA total of 1415 patients were included, with 540(38.1%) ACP, 668(47.2%) IJCP and 207(14.6%) ISCP with a median follow-up of 3.5 years(Inter-quartile range: 1.5–7.5 years). Diabetes occurred at 11.5, 28 and 5.8 years(p < 0.001) while steatorrhea occurred at 16, 24 and 18 years(p = 0.004) after onset for ACP, IJCP and ISCP respectively. Local complications including pseudocysts occurred predominantly in ACP(p < 0.001). Ten-year risk of pancreatic cancer was 0.9%, 0.2% and 5.2% in ACP, IJCP and ISCP, respectively(p < 0.001). Pain resolution occurred more frequently in patients with older age of onset[Multivariate Hazard Ratio(HR):1.7(95%CI:1.4–2.0; p < 0.001)], non-smokers[HR:0.51(95%CI:0.34–0.78); p = 0.002] and in non-calcific CP[HR:0.81(0.66–1.0); p = 0.047]. Occurrence of steatorrhea[HR:1.3(1.03–1.7); p = 0.028] and diabetes[HR:2.7(2.2–3.4); p < 0.001] depended primarily on age at onset. Occurrence of pancreatic cancer depended on age at onset[HR:12.1(4.7–31.2); p < 0.001], smoking-history[HR:6.5(2.2–19.0); p < 0.001] and non-alcoholic etiology[HR:0.14(0.05–0.4); p < 0.001].ConclusionACP, IJCP and ISCP represent distinct entities with different natural course. Age at onset of CP plays a major prognostic role in all manifestations, with alcohol predominantly causing local inflammatory complications.     

Unresponsive or non-compliant steatorrhea in cystic fibrosis?

In 105 pancreatic insufficient CF patients (steatorrhea and low fecal elastase-1 concentrations), the effectiveness of pancreatic enzyme therapy (PET) has been assessed (fecal fat losses and coefficient of fat reabsorption). Eight unresponsive subjects were checked for PET compliance with fecal chymotrypsin assay. Three patients were documented to be non-compliant. Unresponsive patients should undergo evaluation for PET compliance.     

Exocrine pancreatic insufficiency in type 1 and type 2 diabetes mellitus: do we need to treat it? A systematic review

The exocrine and endocrine pancreata are very closely linked both anatomically and physiologically. Abdominal symptoms such as nausea, bloating, diarrhea, steatorrhea, and weight loss can often occur in diabetic patients. Impairments of the exocrine pancreatic function seem to be a frequent complication of diabetes mellitus; however, they are largely overlooked. The aim of this paper is to provide an overview of the current concepts of exocrine pancreatic insufficiency (PEI) in diabetes mellitus. The prevalence and symptoms of PEI in diabetes mellitus, the pathomechanism, and difficulties of diagnosis and therapy of PEI are summarized in this systematic review.