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Category : All ; Cycle : October 2009
Medical Articles
Oct25
Cervix cancer—cervical cancer vaccine. DR NITIN KHUNTETA
Cervix cancer—cervical cancer vaccine

In India, Cervical Cancer is the most common cancer in women. Every year, in India, 132,000 new
cases are diagnosed and 74,000 women die due to this cancer. Globally, Each year, nearly 500,000 new cases are diagnosed of which nearly 270,000 women actually die.

Cervical Cancer is caused by the Human Papillomavirus (HPV).These are classified into 'high-risk' (oncogenic) and 'low-risk' types . 15 oncogenic HPV types have been linked to Cervical Cancer . Low-risk HPV types, such as HPV 6 and 11, are not known to cause cancer,but are responsible for benign genital warts . Globally, HPV 16, 18, 45 and 31 are 4 most common oncogenic HPV types. HPV 16 and 18 together account for 70%.
Together,HPV 16, 18, 45 and 31 are responsible for 80% of Squamous cell carcinomas of the cervix.These same 4 HPV types are also responsible for 90% of Adenocarcinomas of the cervix.

Oncogenic HPV can spread via skin-to-skin genital contact and does not necessarily require penetrative sexual intercourse. Men act as a reservoir of infection, capable of passing on the virus to their female partners who are then at risk of developing Cervical Cancer.

Yes! Cervical Cancer can now be prevented through vaccination.

Cervical cancer vaccine composed of HPV 16 and 18 antigens in the form of VLPs (Virus like particles) combined with a novel adjuvant system called AS04. Adjuvants play a key role in enhancing the immune response elicited by a vaccine. They are used in almost all commercially available vaccines.The most commonly used adjuvant is Aluminium hydroxide. The novel adjuvant system AS04 which combines traditional Aluminium hydroxide with MPL (i.e. Monophosphoryl Lipid A). MPL binds to a novel receptor called the TLR 4 on Antigen presenting cells.This interaction results in a better memory B cell response. Memory B cells are long-lived cells, which then constantly produce a sustained level of antibodies over a long period of time.

Cervical vaccine has been licensed for use in girls and women aged 10-45 years. Antibodies are an important correlate of long-term protection. It is believed that antibody levels that are consistently high over a period of time and are likely to stay high, would provide long term protection against Cervical Cancer.

It is recommended that subjects who receive a first dose of Cervical cancer vaccine complete the three-dose vaccination. If flexibility in the vaccination schedule is necessary, the second dose can be administered between 1 month and 2.5 months after the first dose. Vaccination should be postponed until after completion of pregnancy.

Cervical cancer vaccine is generally safe and well tolerated. The most frequently reported solicited symptoms after administration of vaccine are injection site reactions including pain, redness and swelling. The majority of the solicited local and general symptoms reported are mild to moderate in intensity.


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Oct23
FEMORAL ARTERY ENDARTERITIS-AN UNKNOWN ENTITY
FEMORAL ARTERY ENDARTERITIS IS STILL A RELATIVELY UNKNOWN ENTITY ESPECIALLY AMONG VASCULAR SURGEONS AND CARDIOLOGISTS.NO DOUBT ITS REPORTED INCIDENCE IN LITERATURE IS LESS THAN 1%.


WHAT EXACTLY IS FEMORAL ENDARTERITIS?BASICALLY ITS THE INFECTION OF THE FEMORAL ARTERY AND ITS SURROUNDING TISSUE POST CONVENTIONAL ANGIOGRAM.PATIENT PRESENTS TO YOU WITH PAIN IN THE GROIN GENERALLY WITHIN A WEEK AFTER ANGIO ALONG WITH SYMPTOMS OF SEPSIS AND LOCALISED INFECTION /CELLULITIS IN THE GROIN EXTENDING INVARIABLY OVER THE ABDOMINAL WALL WITH PUS DISCHARGE AT THE PUNCTURE SITE.


WE REPORT A CASE OF FEMORAL ARTERY ENDARTERITIS IN A 73 YEARS OLD MAN WHO REPORTED TO OUR CENTRE IN MOHALI WITH SYMPTOMS OF SEPSIS(HIGH GRADE FEVER,LOW HEAMOGLOBIN,LEUKOCYTOSIS,DERANGED RENAL FUNTION TESTS AND REACTIVE THROMBOCYTOSIS)ALONG WITH SEVERE GROIN PAIN AND SWELLING EXTENDING OVER THE ABDOMINAL WALL.THIS PATIENT UNDERWENT ANGIOGRAM THROUGH THE FEMORAL ROUTE SOME TEN DAYS BACK.HE WAS PUT ON STRONG ANTIBIOTICS BUT TO NO AVAIL.A DOPPLER SCAN AND A CT ANGIO RULED OUT MYCOTIC PSEUDOANEURYSM OF THE FEMORAL VESSELS.


WE TOOK HIM UP FOR IMMEDIATE SURGERY AND FOUND FLORID INFECTION AND CREAMISH YELLOW COLORED PUS EXTENDING FROM THE PUNTURE SITE TO THE GROIN THE ABDOMINAL WALL (SUGGESTIVE OF STAPYLOCOCCUS INFECTION).WE DID A WIDE DEBRIDEMENT OF THE GROIN AND THE FEMORAL ARTERIAL WALL AND REPLACED IT WITH VENOUS PATCH.THE FEMORAL ARTERY WAS COVERED WITH THE TISSUE AROUND TO PREVENT A BLOWOUT.THE GROIN IS LEFT OPEN TILL THE LOCAL INFECTION SUBSIDES AND THE PATIENT IS READY FOR SECONDARY SUTURING.


I FEEL THOUGH UNCOMMON BUT STILL THIS ENTITY LARGELY GOES UNREPORTED /UNDERREPORTED.I HAPPENED TO TALK ABOUT THIS WITH MY COLLEAGUES IN CARDIOLOGY AND VASCULAR FRATERNITY BUT ALL I GET TO KNOW IS THAT THEY HAVE READ ABOUT IT BUT NEVER SEEN IT.ANYWAYS IN A SITUATION LIKE THIS TREATMENT OPTIONS ARE LIMITED AND THE OPERATING SURGEON HAS TO BE VERY AGGRESSIVE IN HIS LINE OF ACTION FOR THESE PATIENTS MAY NEED REPEATED DEBRIDEMENTS AND A POSSIBLE OBTURATOR FORAMEN BYPASS TO SAVE THE LIMB FROM AMPUTATION.
THE ABOVE PICTURE PUBLISHED SHOWS YOU THE SITE OF PUNCTURE WITH PUS DISCHARE ALONG WITH CELLULITIS OF THE NEIGHBOURING TISSUE


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Oct13
THREE POINTS AND NAMASMARAN
First point is: In spiritualism we often hear people preaching that you have to forget yourself in memory of God.

Prima facie this appears to be a horrible idea of complete amnesia or dementia.

The first reaction to such preaching is aversion towards spiritualism. In fact if you are honest and realistic, about genuine personal and social issues, then you develop loathe and disgust about spiritualism.

Those who preach this obviously do not seem to have forgotten themselves or even their petty interests, in memory of God.

Actually; forgetting yourself in memory of God means; being able to get freed from the nagging and harrowing shackles of individualistic or subjective ideas and feelings. NAMASMARAN helps you to gradually get freed from the harassing and obsessive reminders of your own subjective ideas and feelings.

Second point: In spiritualism it is often insisted to the extent of coaxing that you have to give up everything and renounce all the relationships and excepting the one with God.

This also is obviously shocking and repulsive as it induces hatred about all sublime and adorable relationships.

What it actually means is; you acquire the capacity to see every relationship more objectively in the course of time; due to being focused on God i.e. beyond petty self through the practice of NAMASMARAN. As a result; your emotional bonds in all relationships evolve and become mature, subtler and refined.

It is important to understand that of subjective ideas and feelings (memory of petty self) and subjective perceptions about the relatives, friends etc (relationships) should get evolved as a result and NAMASMARAN.

Arbitrarily trying to “forget yourself” or “cut off relations” can be harmful for a common person like me.

One can think over and decide whether to practice or not NAMSMARAN.

The third point: In spiritualism there is a philosophical depiction of reality of different philosophers with different perspectives.

This can be really very harsh on budding minds (if inadvertantly imposed) and induce a knid of cnflicting process in them.

For example when a boy sees the world and comprehends it in a particular way, it is counterproductive for the boy to assume that contrary to his perception is correct (e.g. Brahma Satyam Jagat Mithya) and his perception is wrong!

It is essential to understand that philosophy provides answers to certain questions. Understanding the answers can provide you 50 percent satisfaction and conviction. But remaining 50 per cent clarity comes only through experience.

In life it is always good to ask questions, seek answers and verify the answers on the basis of one’s experiences.

The efforts one must take for one’s evolution to internalize and comprehend experiences are called SADHANA.

In as much as it is wrong to try to blindly forsake your ideas, because some philosophy preaches it, it is also wrong to condemns the answers provided by the philosophy without practicing the SADHANA with some patience; of course similar patience required in any scientific experiment.

NAMASMARAN is one of such globally prevalent SADHANA.


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Oct13
DHARMA AND COSMIC CONSCIOUSNESS
The microcosmic and macrocosmic manifestations of movements, colors, sounds, rhythms, melody, behaviors and the emotional relationships; amongst the nonliving and living forms; are intricate and subtle.

They are beyond one’s intellectual comprehension and even imagination. All that we see and even perceive; is defined and restricted by the characteristics of our sensory receptors and the limitations of cerebral cortex and hence forms a small fraction of what actually “exists” around! Actually the concept of “existence” has also been born from our physiologically limited; though cumulative framework through the civilizations. But even the fraction we perceive may or may not be in consonance with our subjective feelings. This alienation or separation from the core of the nature is the cause of inherent restlessness in most of us.

This separation; manifests in the behavior e.g. such as struggle for existence, which is directed by cruder needs. It manifests later, in struggles and wars motivated by passions, aspirations, and ambitions of asserting, possessing, controlling, and owning and so on. This separation from the core of nature also manifests at personal levels in the strong or weak prejudices and likes and dislikes leading to conflicts.

This clear vision and appreciation of the universe and its; such unfolding at all times, is a blossoming experience. On the backdrop of this orchestra individuals get freed from the subjectivity and blossom into objective existence merged with the core of nature.

Through such blossoming experience we realize that subjectivity i.e. individual differences are inevitable at most of the stages of evolution and in fact; everything in the universe plays a role (delegated to it) in accordance with its state of evolution! One can’t stop wondering about “the management” of this cosmic orchestra!

DHARMA actually means emulation of this cosmic orchestra at individual, social, global and universal levels, by identifying and performing one’s role! The greater the accuracy in emulation, the greater would the individual and the society; experience harmony and melody in universe and vice versa.

This state of identification of one’s role and its assertion marked by victory over restlessness (born out of separation from the core of nature), is implied in the preaching of saints “THEVILE ANANTE TAISECHI RAHAVE, CHITTI ASO DYAVE SAMADHAN”. It is said that it is possible to blossom into this state through NAMASMARAN. In other words, NAMASMARAN is the way to DHARMA, it is the core of DHARMA, and it is the culmination of DHARMA.

One need not merely believe; but can verify the validity of this through experimentation.


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Oct12
how poisonous is poison ivy??
Look Out for the Poisonous Plants they can be anywhere — from the woods to your own backyard. The green leaves of poison plants blend right in with other plants and so it's possible to sit down in a patch of poison ivy without realizing. You might notice later, of course, when you start to itch! To help you identify the plants can grow as a shrub up to about 1.2 metres (3.9 ft) tall, as a groundcover 10–25 cm (3.9–9.8 in) high, or as a climbing vine on various supports. Older vines on substantial supports send out lateral branches that may at first be mistaken for tree limbs. And it's not enough just to know what one kind of poison ivy looks like. Poison ivy comes in several types — and may look different depending on the time of year.

The leaves of poison plants release urushiol, a colorless, odorless oil (called resin) when they're "injured," meaning if they get bumped, torn, or brushed against. Once the urushiol has been released, it can easily get on a person's skin, where it often causes trouble. When the oil is released, the leaves may appear shiny or you may see black spots of resin on them.
It's also possible to get this kind of rash without ever stepping into the woods or directly touching one of the plants. Example Urushiol can be transferred from one person to another. Plus, a person can pick it up from anything that's come in contact with the oil, including your dog that likes to roam the woods! Urushiol even can travel through the air if someone burns some of the plants to clear brush.
Although some people truly are immune to poison ivy, most people develop a rash after coming into contact with poison ivy or the similar plants, poison sumac and poison oak. If you think you are immune because you have never developed a rash before, keep in mind that it can sometimes take multiple exposures or several years before you finally begin to develop an allergic response to urushiol, it is a type of contact dermatitis and can eventually lead to anaphylaxis which is a life threatening condition. Initially Urushiol binds to the skin on contact, where it causes severe itching that develops into reddish colored inflammation or non-colored bumps, and then blistering. These lesions may be treated with Calamine lotion, Burow's solution compresses or baths to relieve discomfort. Over-the-counter products to ease itching - or simply oil/ oatmeal baths and baking soda - are recommended for the treatment of poison ivy. In severe cases, clear fluids ooze from open blistered sores and corticosteroids are then the necessary treatment. The oozing fluids released by itching blisters do not spread the poison as some people think it to be contagious then. Just the areas which have received more poison will react sooner and louder. If poison ivy is burned and the smoke then inhaled, this rash will appear on the lining of the lungs, causing extreme pain and possibly fatal respiratory difficulty. If poison ivy is eaten, the digestive tract, airway, kidneys or other organs can be damaged. A poison ivy rash can last anywhere from one to four weeks, depending on severity and treatment. People who are sensitive to poison ivy can also experience a similar rash from mangoes generally. If you are exposed certain tips would be, you should quickly (within 10 minutes): first, cleanse exposed areas with rubbing alcohol. Next, wash the exposed areas with water only (no soap yet, since soap can move the urushiol, which is the oil from the poison ivy that triggers the rash, around your body and actually make the reaction worse). Now, take a shower with soap and warm water. Lastl , put gloves on and wipe everything you had with you, including shoes, tools, and your clothes, with rubbing alcohol and water. Unfortunately, if you wait more than 10 minutes, the urushiol will likely stay on your skin and trigger the poison ivy rash. You may not be able to stop it on your skin, but you might still scrub your nails and wipe off your shoes, etc., so that you don't spread the urushiol to new areas. And in cases rash is sever you must consult a dermatologist. Remember that poison ivy isn't contagious though, so touching the rash won't actually spread it. Preventing Poison Ivy by wearing long pants and a shirt with long sleeves, boots, gloves and cotton socks especially for kids who are more at risk should do the trick.
"One, two, three? Don't touch me." Is a famous synonym for this dangerous plant and is the best advise till date.


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Oct12
what is lichen planus???
Lichen planus The name "lichen" refers to the lichen plant which grows on rocks or trees, and "planus" means flat. It is a common inflammatory disease that usually affects the skin and mucosa of mouth and genitals. It causes inflammation, itching, and distinctive purplish hue colour in the skin lesions. It is not an infectious disease, it does not appear to be inherited, and it is not related to nutrition. It affects about one to two percent of the general population. The dermatologist suspects lichen planus based on the distinctive appearance of the lesions and sometimes a skin or mouth biopsy is needed to confirm the diagnosis. The skin lesions are classically purple, plane topped, polygonal, papules, extremely pruritic occurring generally first around the ankles, wrist,lower back but can involve the whole body. Lichen Planus of the mouth most commonly occurs inside the cheeks, but can affect the tongue, lips, and gums. Oral Lichen Planus is more difficult to treat and typically lasts longer than the skin. About one in five people who have oral lesions also have skin lichen planus. Nail changes have been observed in Lichen Planus. The majority of nail changes results from damage to the nail matrix, or nail root and can lead to total dystrophy and destruction of the nail.
The goal of treatment is to reduce the symptoms and speed healing of the skin lesions. If symptoms are mild, no treatment may be needed.
Treatments may include: Antihistamines (anti-allergic medicines), If one has mouth lesions, lidocaine mouth washes may numb the area temporarily and make eating more comfortable. Topical corticosteroids (such as triamcinolone acetonide cream) or oral corticosteroids (such as prednisone) may be prescribed to reduce inflammation and suppress immune responses. Corticosteroids may be injected directly into a lesion also. Topical retinoic acid cream (a form of vitamin A) and other ointments or creams may reduce itching and inflammation and may aid healing. Occlusive dressings may be placed over topical medications to protect the skin from scratching. A specific form of ultraviolet light treatment called PUVA may be needed in selective cases.
Lichen Planus of the skin is characterized by reddish-purple, flat-topped bumps that may be very itchy. Some may have a white lacy appearance called Wickham's Striae. They can be anywhere on the body, but seem to favor the inside of the wrists and ankles.
Lichen planus is generally not harmful and may resolve with treatment, but it can persist for months to years. Oral lichen planus usually clears within 18 months. Patients with oral lichen planus (mouth ulcers) may be at a slightly increased risk of developing oral cancer. Because of this risk I recommend discontinuing the use of alcohol and tobacco products, which also increase the risk and also to have regular visits to the dermatologist, every six to twelve months - for oral cancer screening. Spicy foods, citrus juices, tomato products, caffeinated drinks like coffee and cola, and crispy foods like toast and corn chips can aggravate Lichen Planus especially if there are open sores in the mouth.


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Oct12
A NOVEL FORMULATION FOR TREATING SICKLE CELL DISEASE/HEMOGLOBINOPATHIES
Sickle Cell Anaemia is a genetic blood disorder caused by abnormal hemoglobin that damages and deforms red blood cells. The abnormal red cells break down, causing anemia, and obstruct blood vessels, leading to recurrent episodes of sever pain and multiorgan ischemic damage. The Indian System of Medicine Ayurveda has valuable information about herbs and mineral for human uses.
T-AYU-HM™ is an extract of eight Indian origin herbal plants and three purified minerals. In laboratory studies it strongly inhibits sickling of red cells in patients with sickle cell diseases and it has been shown in initial clinical evaluation in state of Gujarat, India. Preparations and standardizations are as FDA standard.
The working principal involved in the T-AYU-HM™.

* Reduce the pains of Sickle cell Diseases.
* Maintain the Hemoglobin level as per SCA patients' need.
* Reduce crisis episode
* Protect spleen, heart, liver and kidney.
* Promote health and enhance the quality of life.


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Oct05
BREAST HEALTH-BREAST CANCER
BREAST CANCER –BREAST HEALTH--------
DR NITIN KHUNTETA
MBBS, MS ( GEN. SURGERY),
M Ch (SURGICAL ONCOLOGY),
DNB (SURGICAL ONCOLOGY).
CONSULTANT SURGICAL ONCOLOGIST, Bhagwan Mahaveer Cancer hospital & Research Centre, Jaipur

The incidence of breast cancer in India is on the rise and is rapidly becoming the number one cancer in females pushing the cervical cancer to the second spot.
The rise is being documented mainly in the metros. It is reported that one in 22 women in India is likely to suffer from cancer during her lifetime, while the figure is definitely more in America with one in eight being a victim of this deadly cancer.
Breast cancer is the most common form of cancer among women. According to a study by International Agency for Research on Cancer (IARC), there will be approximately 250,000 new cases of breast cancer in India by 2015. At present, India reports around 100,000 new cases annually.
Globally, every three minutes a woman is diagnosed with breast cancer in the world, amounting to one million cases annually. The incidence could go up by 50 percent to 1.5 million by 2020, says the World Cancer Report.
The chances of survival and cures for breast cancer is as high as 90 percent after complete treatment.
Breast cancer will become an epidemic in India in near future. Before it becomes the epidemic we should take appropriate measures to prevent development of breast cancer.
AVOIDING THE RISK FACTORS DECREASES THE CHANCE OF DEVELOPMENT OF BREAST CANCER ---
The rise in the incidence of breast cancer is due to changing lifestyles, i.e marrying late, the average child bearing age has increased to 30 and sometimes even beyond that, early weaning from breast feeding, the use of combined estrogen and progestin hormone replacement therapy (HRT) , obesity & lack of physical activity.
THE SMALLER THE CANCER IN BODY THE HIGER CHANCE OF CURE------ There are four stages of breast cancer. Stage 1 to 4. For to diagnose at earlier stage the following recommendation should be followed—
 Screening mammography---mammography is so far the only screening method that has been consistently proven to reduce deaths from breast cancer. It is considered the gold standard of screening, while breast self examination is, at best, a supplement to regular mammograms and breast exams by a doctor.
RECOMMENDATIONS—
• Women age 40 and older should have a screening mammogram every year, and should continue to do so for as long as they are in good health.
• Women at moderately increased risk (15% to 20% lifetime risk) should have their yearly mammogram.
• Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year.
• Schedule the mammogram when the breasts are not tender or swollen to help reduce discomfort and to assure a good picture. Try to avoid the week just before the menstrual period.
• On the day of the exam, don’t wear deodorant or antiperspirant; some of these contain substances that can interfere with the reading of the mammogram by appearing on the x-ray film as white spots.
• Discuss any new findings or problems in your breasts with your doctor or nurse before having a mammogram.
• To bring previously done mammograms so that they can be compared to the new ones.

 Breast self examination-------Goal- to report any breast changes to a doctor or nurse right away.
• Systematic step-by-step approach to examining the look and feel of one’s breasts.
• What to look-- lump or swelling, skin irritation or dimpling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, a discharge other than breast milk, or a change in the size of one breast,
• Best time for a woman to examine her breasts is when the breasts are not tender or swollen.
• Women who are pregnant, breast feeding, or have breast implants can also choose to examine their breasts regularly.
• Women who examine their breasts should have their technique reviewed during their periodic health exams by their health care professional.

 Clinical breast examination.---- Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional preferably every 3 years. After age 40, women should have a breast exam by a health professional every year.
 ACS RECOMMENDATIONS—
• Women age 40 and older should have a screening mammogram every year, and should continue to do so for as long as they are in good health.
• Women at moderately increased risk (15% to 20% lifetime risk) should have their yearly mammogram.
• Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year.
The treatment protocol for breast cancer depends on the stage of the cancer & general physical condition of the patient.
Surgery is the main modality for early & locally advanced breast cancer.
The two types of surgery to treat breast cancer are:
1--Surgery to remove the entire breast & axillary lymph nodes i.e radical mastectomy.
2--Surgery to remove just the area of the breast that contains cancer & axillary dissection (breast-conserving surgery) followed by radiation treatment.
Studies now show that breast-conserving surgery followed by radiation therapy is as good as mastectomy in treating early-stage breast cancer (Breast Conservation Trials, NSABP B-06).
Breast conservation surgery is not recommended in patients with---
Two or more tumors in separate areas of breast, H/O prior therapeutic irradiation to the breast, Pregnancy, Women with certain connective tissue diseases. e.g systemic scleroderma, lupus erythematosus, polymyositis, dermatomyositis, and mixed-connective tissue disorders. Women with a tumor larger than 5 cm (2 inches) that doesn't shrink very much with chemotherapy in small & medium size breast.
After breast conserving cancer surgery & subsequent radiotherapy, up to 50 to 60 % of woman have a residual deformity that requires surgical correction, by performing immediate remodelling of the breast at the same time as cancer removal. Plastic surgical techniques (oncoplastic & flap surgery ) should be integrated with the original operation .


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Oct05
New Guidelines Address Management of Common Bile Duct Stones CME
"The last 30 years has seen major developments in the management of gallstone related disease, which in the United States alone costs over 6 billion dollars per annum to treat," write Earl Jon Williams, from the British Society of Gastroenterology (BSG) and the Royal Liverpool University Hospital, Liverpool, United Kingdom, and colleagues. "As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. It is with this in mind that the following guidelines have been written."
New imaging techniques allow accurate visualization of the biliary system without requiring duct instrumentation. These include magnetic resonance (MR) cholangiography and endoscopic ultrasound (EUS). Use of endoscopic retrograde cholangiopancreatography (ERCP) is now widespread and is considered a routine procedure. Laparoscopic cholecystectomy has largely replaced open cholecystectomy, and it is often accompanied by laparoscopic exploration of the common bile duct (LCBDE).
The BSG commissioned these guidelines, which were subsequently reviewed, revised, and endorsed by the Clinical Standards and Services Committee of the BSG, the BSG Endoscopy Committee, the ERCP stakeholder group, the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, and the Royal College of Radiologists.
After a preliminary search of the literature in 2004 of PubMed and MEDLINE, the findings were summarized and were presented to the BSG Endoscopy Committee, which developed principal clinical questions to be addressed by the guidelines. A multidisciplinary guideline-writing group then wrote provisional guidelines.
Some of the specific recommendations are as follows:
• Hepatobiliary cases should be discussed in a multidisciplinary setting (grade C).
• Symptomatic patients in whom evaluation suggests ductal stones should undergo extraction if possible (grade B).
• Transabdominal ultrasound scanning (USS) is recommended as a preliminary investigation for CBDS, but it is not a sensitive test for this condition (grade B).
• EUS and MR cholangiography are both highly effective at confirming CBDS; patient suitability, accessibility, and local expertise should help decide between the 2 procedures (grade B).
• When performing endoscopic stone extraction (ESE), the endoscopist should be assisted by a technician or radiologist who can help with fluoroscopy, a nurse for safety monitoring, and an additional endoscopy assistant or nurse to manage guide wires and other technical aspects as needed (grade C).
• ERCP should be done only in patients who are expected to require an intervention; it is not recommended for use solely as a diagnostic test (grade B).
• Full blood count and prothrombin time/international normalized ratio (PT/INR) should be performed within 72 hours before biliary sphincterotomy for ductal stones; patients with abnormal clotting should undergo subsequent management based on locally agreed guidelines (grade B).
• For patients treated with anticoagulants but who are at low risk for thromboembolism, anticoagulants should be discontinued before endoscopic stone extraction if biliary sphincterotomy is planned (grade B) as should newer antiplatelet agents (eg, clopidogrel), 7 to 10 days before biliary sphincterotomy (grade C). Use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and low-dose heparin should not be considered a contraindication to biliary sphincterotomy (grade B).
• Patients with biliary obstruction or previous features of biliary sepsis should receive prophylactic antibiotics (grade A).
• Sphincterotomy initiated with use of pure cut may be preferred in patients with risk factors for post-ERCP pancreatitis but not biliary sphincterotomy–induced hemorrhage (grade A).
• In most patients undergoing stone extraction, balloon dilation of the papilla should be avoided because the risk for severe post-ERCP pancreatitis is increased vs biliary sphincterotomy (grade A).
• Short-term use of a biliary stent, followed by further endoscopy or surgery, is recommended to ensure adequate biliary drainage in patients with CBDS that have not been extracted (grade B).
• Use of a biliary stent as sole treatment of CBDS should be limited to patients with limited life expectancy or prohibitive surgical risk, or both (grade A).
• Pre-cut is a risk factor for complication and should be used only by those with appropriate training and experience and only in patients for whom subsequent endoscopic treatment is essential (grade B).
• Operative risk should be evaluated before scheduling intervention, and endoscopic therapy should be considered as an alternative in high-risk patients (grade B).
• Intraoperative cholangiography or laparoscopic ultrasound can detect CBDS in patients who are suitable for surgical exploration or postoperative ERCP (grade B).
• In patients undergoing laparoscopic cholecystectomy, transcystic and transductal exploration of the common bile duct are both considered appropriate for removal of CBDS (grade A).
• When minimally invasive techniques fail to achieve duct clearance, open surgical exploration is still considered to be an important treatment option (grade B).
The guidelines also discuss supplementary treatments including mechanical lithotripsy, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy and laser lithotripsy, percutaneous treatment, and oral ursodeoxycholic acid. Management of specific clinical scenarios is also presented.
"Biliary sphincterotomy and endoscopic stone extraction (ESE) is recommended as the primary form of treatment for patients with CBDS post cholecystectomy," the authors of the guidelines write. "Cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones, unless there are specific reasons for considering surgery inappropriate. Patients with CBDS undergoing laparoscopic cholecystectomy may be managed by laparoscopic common bile duct exploration (LCBDE) at the time of surgery, or undergo peri-operative ERCP."

Clinical Context
In the last 3 decades, major developments in the management of gallstone-related disease have extended the range of suitable options for evaluation and treatment of CBDS. The high healthcare costs associated with this condition (> 6 billion dollars per year in the United States alone) warrant new guidelines providing recommendations for clinical management.
ERCP is now widely available and is performed routinely, and laparoscopy has mostly obviated the need for open cholecystectomy. New imaging techniques facilitating less invasive visualization of the biliary tree include MR cholangiography and EUS.

Study Highlights
• Multidisciplinary management is recommended for hepatobiliary cases.
• Transabdominal USS is not a sensitive test for CBDS, but it is suitable as a preliminary investigation.
• EUS and MR cholangiography are both highly effective at confirming CBDS. Patient-specific factors, local availability, and local expertise should guide the choice between the 2 procedures.
• Symptomatic patients with suspected ductal stones based on evaluation should undergo extraction if possible.
• Biliary sphincterotomy and ESE are recommended as the primary forms of treatment of patients with CBDS postcholecystectomy.
• Unless there are specific reasons for considering surgery inappropriate, cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones.
• Patients with CBDS undergoing laparoscopic cholecystectomy may be treated by LCBDE at the time of surgery or undergo perioperative ERCP.
• Endoscopists performing ESE should be assisted by a technician or radiologist who can help with fluoroscopy, a nurse for safety monitoring, and an additional endoscopy assistant or nurse to manage technical aspects as needed.
• ERCP should be done only in patients who are expected to require an intervention; it is not recommended solely for diagnostic use.
• Full blood count and PT/INR should be performed within 72 hours before biliary sphincterotomy for ductal stones; patients with abnormal clotting should be treated according to local protocol.
• For patients treated with anticoagulants but at low risk for thromboembolism, anticoagulants should be discontinued before ESE if biliary sphincterotomy is planned (grade B) as should newer antiplatelet agents. Use of aspirin, NSAIDs, and low-dose heparin should not be considered a contraindication to biliary sphincterotomy.
• Antibiotic prophylaxis should be given to patients with biliary obstruction or previous features of biliary sepsis.
• Sphincterotomy initiated with use of pure cut may be preferred in patients with risk factors for post-ERCP pancreatitis but not biliary sphincterotomy–induced hemorrhage.
• Balloon dilation of the papilla should be avoided in most patients undergoing stone extraction because the risk for severe post-ERCP pancreatitis is increased vs biliary sphincterotomy.
• For CBDS that have not been extracted, short-term use of a biliary stent, followed by further endoscopy or surgery, is recommended to ensure adequate biliary drainage.
• Only patients with limited life expectancy or prohibitive surgical risk, or both, should undergo use of a biliary stent as sole treatment of CBDS.
• Pre-cut increases the risk for complication and should be used only by those with appropriate training and experience and only for patients in whom subsequent endoscopic treatment is essential.
• Operative risk should be evaluated before surgery is scheduled. In high-risk patients, endoscopic therapy should be considered as an alternative.
• In patients deemed suitable for surgical exploration or postoperative ERCP, intraoperative cholangiography, or laparoscopic ultrasound can detect CBDS.
• Transcystic and transductal exploration of the common bile duct are both considered appropriate for removal of CBDS in patients undergoing laparoscopic cholecystectomy.
• Open surgical exploration is still considered to be an important treatment option when minimally invasive techniques do not achieve duct clearance.
• Supplementary treatments may include mechanical lithotripsy, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy and laser lithotripsy, percutaneous treatment, and oral ursodeoxycholic acid.


Pearls for Practice
• Transabdominal USS is recommended as a preliminary investigation for CBDS, but it is not a sensitive test for this condition. EUS and MR cholangiography are both highly effective at confirming CBDS; patient suitability, accessibility, and local expertise should help decide between the 2 procedures.
• Biliary sphincterotomy and ESE are the primary forms of treatment recommended for patients with CBDS postcholecystectomy. For all patients with CBDS and symptomatic gallbladder stones, cholecystectomy is recommended, unless there are specific reasons for considering surgery inappropriate. Patients with CBDS undergoing laparoscopic cholecystectomy may be treated by LCBDE at the time of surgery or undergo perioperative ERCP.


Based on the BSG guidelines, which of the following statements about evaluation of CBDS is correct?

Transabdominal USS is a sensitive test for CBDS

EUS is significantly less effective than MR cholangiography for confirming CBDS

EUS is significantly more effective than MR cholangiography for confirming CBDS

Transabdominal USS is recommended as a preliminary investigation for CBDS

Based on the BSG guidelines, which of the following statements about treatment of CBDS is not correct?

Perioperative ERCP is not recommended for patients with CBDS undergoing laparoscopic cholecystectomy

Biliary sphincterotomy and ESE are recommended as the primary forms of treatment of patients with CBDS postcholecystectomy

Cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones, unless they are not surgical candidates

Patients with CBDS undergoing laparoscopic cholecystectomy may be treated by LCBDE at the time of surgery


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Oct05
New Guidelines Address Management of Common Bile Duct Stones
"The last 30 years has seen major developments in the management of gallstone related disease, which in the United States alone costs over 6 billion dollars per annum to treat," write Earl Jon Williams, from the British Society of Gastroenterology (BSG) and the Royal Liverpool University Hospital, Liverpool, United Kingdom, and colleagues. "As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. It is with this in mind that the following guidelines have been written."

New imaging techniques allow accurate visualization of the biliary system without requiring duct instrumentation. These include magnetic resonance (MR) cholangiography and endoscopic ultrasound (EUS). Use of endoscopic retrograde cholangiopancreatography (ERCP) is now widespread and is considered a routine procedure. Laparoscopic cholecystectomy has largely replaced open cholecystectomy, and it is often accompanied by laparoscopic exploration of the common bile duct (LCBDE).

The BSG commissioned these guidelines, which were subsequently reviewed, revised, and endorsed by the Clinical Standards and Services Committee of the BSG, the BSG Endoscopy Committee, the ERCP stakeholder group, the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, and the Royal College of Radiologists.

After a preliminary search of the literature in 2004 of PubMed and MEDLINE, the findings were summarized and were presented to the BSG Endoscopy Committee, which developed principal clinical questions to be addressed by the guidelines. A multidisciplinary guideline-writing group then wrote provisional guidelines.

Some of the specific recommendations are as follows:

Hepatobiliary cases should be discussed in a multidisciplinary setting (grade C).
Symptomatic patients in whom evaluation suggests ductal stones should undergo extraction if possible (grade B).
Transabdominal ultrasound scanning (USS) is recommended as a preliminary investigation for CBDS, but it is not a sensitive test for this condition (grade B).
EUS and MR cholangiography are both highly effective at confirming CBDS; patient suitability, accessibility, and local expertise should help decide between the 2 procedures (grade B).
When performing endoscopic stone extraction (ESE), the endoscopist should be assisted by a technician or radiologist who can help with fluoroscopy, a nurse for safety monitoring, and an additional endoscopy assistant or nurse to manage guide wires and other technical aspects as needed (grade C).
ERCP should be done only in patients who are expected to require an intervention; it is not recommended for use solely as a diagnostic test (grade B).
Full blood count and prothrombin time/international normalized ratio (PT/INR) should be performed within 72 hours before biliary sphincterotomy for ductal stones; patients with abnormal clotting should undergo subsequent management based on locally agreed guidelines (grade B).
For patients treated with anticoagulants but who are at low risk for thromboembolism, anticoagulants should be discontinued before endoscopic stone extraction if biliary sphincterotomy is planned (grade B) as should newer antiplatelet agents (eg, clopidogrel), 7 to 10 days before biliary sphincterotomy (grade C). Use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and low-dose heparin should not be considered a contraindication to biliary sphincterotomy (grade B).
Patients with biliary obstruction or previous features of biliary sepsis should receive prophylactic antibiotics (grade A).
Sphincterotomy initiated with use of pure cut may be preferred in patients with risk factors for post-ERCP pancreatitis but not biliary sphincterotomy–induced hemorrhage (grade A).
In most patients undergoing stone extraction, balloon dilation of the papilla should be avoided because the risk for severe post-ERCP pancreatitis is increased vs biliary sphincterotomy (grade A).
Short-term use of a biliary stent, followed by further endoscopy or surgery, is recommended to ensure adequate biliary drainage in patients with CBDS that have not been extracted (grade B).
Use of a biliary stent as sole treatment of CBDS should be limited to patients with limited life expectancy or prohibitive surgical risk, or both (grade A).
Pre-cut is a risk factor for complication and should be used only by those with appropriate training and experience and only in patients for whom subsequent endoscopic treatment is essential (grade B).
Operative risk should be evaluated before scheduling intervention, and endoscopic therapy should be considered as an alternative in high-risk patients (grade B).
Intraoperative cholangiography or laparoscopic ultrasound can detect CBDS in patients who are suitable for surgical exploration or postoperative ERCP (grade B).
In patients undergoing laparoscopic cholecystectomy, transcystic and transductal exploration of the common bile duct are both considered appropriate for removal of CBDS (grade A).
When minimally invasive techniques fail to achieve duct clearance, open surgical exploration is still considered to be an important treatment option (grade B).
The guidelines also discuss supplementary treatments including mechanical lithotripsy, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy and laser lithotripsy, percutaneous treatment, and oral ursodeoxycholic acid. Management of specific clinical scenarios is also presented.

"Biliary sphincterotomy and endoscopic stone extraction (ESE) is recommended as the primary form of treatment for patients with CBDS post cholecystectomy," the authors of the guidelines write. "Cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones, unless there are specific reasons for considering surgery inappropriate. Patients with CBDS undergoing laparoscopic cholecystectomy may be managed by laparoscopic common bile duct exploration (LCBDE) at the time of surgery, or undergo peri-operative ERCP."

The authors of the guidelines have disclosed no relevant financial relationships.

Gut. Published online March 5, 2008.

Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:

Describe recommendations regarding new imaging techniques for evaluation of patients with common bile duct stones.
Describe recommendations regarding treatment of patients with common bile duct stones.
Clinical Context
In the last 3 decades, major developments in the management of gallstone-related disease have extended the range of suitable options for evaluation and treatment of CBDS. The high healthcare costs associated with this condition (> 6 billion dollars per year in the United States alone) warrant new guidelines providing recommendations for clinical management.

ERCP is now widely available and is performed routinely, and laparoscopy has mostly obviated the need for open cholecystectomy. New imaging techniques facilitating less invasive visualization of the biliary tree include MR cholangiography and EUS.

Study Highlights
Multidisciplinary management is recommended for hepatobiliary cases.
Transabdominal USS is not a sensitive test for CBDS, but it is suitable as a preliminary investigation.
EUS and MR cholangiography are both highly effective at confirming CBDS. Patient-specific factors, local availability, and local expertise should guide the choice between the 2 procedures.
Symptomatic patients with suspected ductal stones based on evaluation should undergo extraction if possible.
Biliary sphincterotomy and ESE are recommended as the primary forms of treatment of patients with CBDS postcholecystectomy.
Unless there are specific reasons for considering surgery inappropriate, cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones.
Patients with CBDS undergoing laparoscopic cholecystectomy may be treated by LCBDE at the time of surgery or undergo perioperative ERCP.
Endoscopists performing ESE should be assisted by a technician or radiologist who can help with fluoroscopy, a nurse for safety monitoring, and an additional endoscopy assistant or nurse to manage technical aspects as needed.
ERCP should be done only in patients who are expected to require an intervention; it is not recommended solely for diagnostic use.
Full blood count and PT/INR should be performed within 72 hours before biliary sphincterotomy for ductal stones; patients with abnormal clotting should be treated according to local protocol.
For patients treated with anticoagulants but at low risk for thromboembolism, anticoagulants should be discontinued before ESE if biliary sphincterotomy is planned (grade B) as should newer antiplatelet agents. Use of aspirin, NSAIDs, and low-dose heparin should not be considered a contraindication to biliary sphincterotomy.
Antibiotic prophylaxis should be given to patients with biliary obstruction or previous features of biliary sepsis.
Sphincterotomy initiated with use of pure cut may be preferred in patients with risk factors for post-ERCP pancreatitis but not biliary sphincterotomy–induced hemorrhage.
Balloon dilation of the papilla should be avoided in most patients undergoing stone extraction because the risk for severe post-ERCP pancreatitis is increased vs biliary sphincterotomy.
For CBDS that have not been extracted, short-term use of a biliary stent, followed by further endoscopy or surgery, is recommended to ensure adequate biliary drainage.
Only patients with limited life expectancy or prohibitive surgical risk, or both, should undergo use of a biliary stent as sole treatment of CBDS.
Pre-cut increases the risk for complication and should be used only by those with appropriate training and experience and only for patients in whom subsequent endoscopic treatment is essential.
Operative risk should be evaluated before surgery is scheduled. In high-risk patients, endoscopic therapy should be considered as an alternative.
In patients deemed suitable for surgical exploration or postoperative ERCP, intraoperative cholangiography, or laparoscopic ultrasound can detect CBDS.
Transcystic and transductal exploration of the common bile duct are both considered appropriate for removal of CBDS in patients undergoing laparoscopic cholecystectomy.
Open surgical exploration is still considered to be an important treatment option when minimally invasive techniques do not achieve duct clearance.
Supplementary treatments may include mechanical lithotripsy, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy and laser lithotripsy, percutaneous treatment, and oral ursodeoxycholic acid.
Pearls for Practice
Transabdominal USS is recommended as a preliminary investigation for CBDS, but it is not a sensitive test for this condition. EUS and MR cholangiography are both highly effective at confirming CBDS; patient suitability, accessibility, and local expertise should help decide between the 2 procedures.
Biliary sphincterotomy and ESE are the primary forms of treatment recommended for patients with CBDS postcholecystectomy. For all patients with CBDS and symptomatic gallbladder stones, cholecystectomy is recommended, unless there are specific reasons for considering surgery inappropriate. Patients with CBDS undergoing laparoscopic cholecystectomy may be treated by LCBDE at the time of surgery or undergo perioperative ERCP.


Based on the BSG guidelines, which of the following statements about evaluation of CBDS is correct?
Transabdominal USS is a sensitive test for CBDS
EUS is significantly less effective than MR cholangiography for confirming CBDS
EUS is significantly more effective than MR cholangiography for confirming CBDS
Transabdominal USS is recommended as a preliminary investigation for CBDS


Based on the BSG guidelines, which of the following statements about treatment of CBDS is not correct?
Perioperative ERCP is not recommended for patients with CBDS undergoing laparoscopic cholecystectomy
Biliary sphincterotomy and ESE are recommended as the primary forms of treatment of patients with CBDS postcholecystectomy
Cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones, unless they are not surgical candidates
Patients with CBDS undergoing laparoscopic cholecystectomy may be treated by LCBDE at the time of surgery


Category (Gastrointestinal Problems)  |   Views (16344)  |  User Rating
Rate It


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