BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is a method used to decrease portal hypertension. Biliary stricture is the rarest of the complications associated with this procedure with only 12 cases previously reported in the literature. None of these cases have documented the resolution of biliary stenosis induced by a stent graft. The only curative solutions reported are liver transplantation or bypassing the stenosis with an artificial biliary tract using advanced endoscopic techniques. CASE SUMMARY: This is the first reported case of biliary obstruction secondary to TIPS placement in a transplanted liver. In our patient, a portosystemic shunt was created to treat severe veno-occlusive liver graft disease manifesting itself primarily by fluid retention. A cholestatic liver lesion and cholangitis with abscesses developed due to a stent graft-induced stricture in the dorsal segment of the right hepatic duct and the stricture diminished following percutaneous drainage. Endoscopic drainage was performed after unsuccessful removal of the percutaneous catheter resulting in a bilio-cutaneous fistula. Although the liver graft now functions well, the stricture remains refractory even after 44 mo of treatment. CONCLUSION: Biliary strictures caused by TIPS in both transplanted and native livers seem refractory to endoscopic treatment.
- Publikační typ
- kazuistiky MeSH
BACKGROUND: Pancreas transplantation (PTx) represents the method of choice in type 1 diabetic patients with conservatively intractable hypoglycemia unawareness syndrome. In 2005, the Institute for Clinical and Experimental Medicine (IKEM) launched a program to investigate the safety potential of islet transplantation (ITx) in comparison to PTx. AIM: This study aims to compare the results of PTx and ITx regarding severe hypoglycemia elimination, metabolic control, and complication rate. METHODS: We analyzed the results of 30 patients undergoing ITx and 49 patients treated with PTx. All patients were C-peptide-negative and suffered from hypoglycemia unawareness syndrome. Patients in the ITx group received a mean number of 12,349 (6,387-15,331) IEQ/kg/person administered percutaneously into the portal vein under local anesthesia and radiological control. The islet number was reached by 1-3 applications, as needed. In both groups, we evaluated glycated hemoglobin, insulin dose, fasting and stimulated C-peptide, frequency of severe hypoglycemia, and complications. We used the Mann Whitney test, Wilcoxon signed-rank test, and paired t-test for analysis. We also individually assessed the ITx outcomes for each patient according to recently suggested criteria established at the EPITA meeting in Igls. RESULTS: Most of the recipients showed a significant improvement in metabolic control one and two years after ITx, with a significant decrease in HbA1c, significant elevation of fasting and stimulated C-peptide, and a markedly significant reduction in insulin dose and the frequency of severe hypoglycemia. Seventeen percent of ITx recipients were temporarily insulin-independent. The results in the PTx group were comparable to those in the ITx group, with 73% graft survival and insulin independence in year 1, 68% 2 years and 55% 5 years after transplantation. There was a higher rate of complications related to the procedure in the PTx group. Severe hypoglycemia was eliminated in the majority of both ITx and PTx recipients. CONCLUSION: This report proves the successful initiation of pancreatic islet transplantation in a center with a well-established PTx program. ITx has been shown to be the method of choice for hypoglycemia unawareness syndrome, and may be considered for application in clinical practice if conservative options are exhausted.
- MeSH
- C-peptid krev MeSH
- diabetes mellitus 1. typu epidemiologie etiologie terapie MeSH
- dospělí MeSH
- hodnocení rizik MeSH
- hypoglykemie epidemiologie terapie MeSH
- krevní glukóza metabolismus MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- následné studie MeSH
- přežívání štěpu MeSH
- retrospektivní studie MeSH
- syndrom MeSH
- transplantace Langerhansových ostrůvků * škodlivé účinky metody MeSH
- transplantace slinivky břišní * škodlivé účinky metody MeSH
- výběrové chování MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Whipple disease (WD) is a rare systemic disorder caused by the bacteria Tropheryma whipplei. In its classic form, it manifests with gastrointestinal problems including diarrhea, abdominal pain, and weight loss. However, various other systems can be affected, including the central nervous system (CNS). Even more rarely, the CNS is primarily affected without gastrointestinal symptoms and with a negative small bowel biopsy. The incidence of primary CNS WD is unknown. We report the case of a young female with the primary CNS form of WD. In this report, we highlight the main clinical features and diagnostic procedures that lead to the diagnosis and comment on the treatment and clinical response. We stress the importance of neuroimaging and brain biopsy. A unique feature of this case is that the patient has been followed up for 12 years. At the time of diagnosis, no neurological manifestations were detected, although a tumor-like lesion in the right temporal lobe and hypothalamic infiltration were present on magnetic resonance imaging (MRI). The first neurological manifestations developed 2 years later despite recommended antibiotic treatment, with cognitive impairment developing more than 10 years later. According to the MRI findings and clinical course, the disease was active for several years when multiple lesions on MRI appeared despite antibiotic therapy. In the discussion, we compare the present case with similar cases previously reported and we elaborate on the similarities and discrepancies in clinical features, diagnostic procedures, results, and treatment options.
- Publikační typ
- časopisecké články MeSH
Názory na význam asymptomatické významné stenózy v oblasti karotických artérií pro další osud pacientů a na nejvhodnější léčebný postup nejsou jednotné. Indikace případného revaskularizačního výkonu závisí na řadě dalších faktorů – stupni stenózy, stenózách dalších tepen zásobujících mozkovou tkáň, procentu komplikací na intervenčním (katetrizačním či chirurgickém) pracovišti, na které je pacient referován, na celkovém zdravotním stavu a zřejmě i na pohlaví pacienta. Ošetřující lékař se v podstatě rozhoduje mezi třemi možnostmi postupu: katetrizačním řešením (perkutánní angioplastikou s implantací stentu), chirurgickým řešením (endarterektomií) či pouze razantním ovlivněním všech kardiovaskulárních rizikových faktorů, které je samozřejmě indikováno i v případě provedení revaskularizačního výkonu. Postoje jednotlivých odborníků i odborných společností jsou často odlišné a u stejného pacienta je často jednotlivými specialisty doporučován rozdílný postup. Dalším nevyřešeným problémem je nález asymptomatické významné stenózy karotické tepny a její následné řešení u pacienta před rozsáhlým operačním výkonem, především v cévní oblasti (nejčastěji revaskularizačním výkonem na koronárních tepnách).
The management of haemodynamicaly significant but asymptomatic carotid stenosis is still the matter of controversy. Attending physician should decide whether just treat aggressively cardiovascular risk factors or whether refer the patient to angioplasty (with stent implantation) or endarterectomy. This decision depends on several factors like the grade of artery stenosis, involvement of other arteries supplying brain, rate of complications of revascularization procedures in particular catheterization or surgical centre, on the health status of the patient and potentially on gender. Obviously, management of all cardiovascular risk factors in patient with carotid stenosis is indicated in any case. However, the recommendations of experts and even professional societies frequently differ from each other. Even more challenging are decisions in patients with significant carotid stenoses, who are scheduled for major (mainly vascular) surgery, especially coronary artery bypass graft surgery.
- MeSH
- cévní mozková příhoda komplikace prevence a kontrola terapie MeSH
- hodnocení rizik MeSH
- kardiovaskulární chirurgické výkony metody využití MeSH
- kardiovaskulární nemoci komplikace mortalita terapie MeSH
- kvalita života MeSH
- lidé MeSH
- mortalita MeSH
- příčina smrti MeSH
- primární prevence metody MeSH
- rizikové faktory MeSH
- stenóza arteria carotis diagnóza chirurgie terapie MeSH
- ultrasonografie využití MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- randomizované kontrolované studie MeSH
