Postgrad Med J 2003;79:181–184 181 clearance of bile duct stones resistant to Postgrad Med J: first published as 10.1136/pmj.79.929.181 on 1 March 2003. Downloaded from SELF ASSESSMENT ANSWERS endoscopic extraction. Gastrointest Endosc 2001;53:27–32. 2 Kratzer W, Mason R, Grammer S, et al. Treatment options for session.367The success rate of this procedure, Difficult bile duct stone recurrence after with complete clearance of the common bile endoscopy and exracorporeal shock wave common bile duct stones duct is between 80% and 90%.1–3 6 lithotripsy. Hepatogastroenterology The main complication is cholangitis (1%– 1998;45:910–6. Q1: What are the treatment options 8%) and this is reduced by use of prophylactic 3 White DM, Correa RJ, Gibbons RP, et al. for this patient? 16 Exracorporeal shock wave lithotripsy for bile antibiotics. Procedure related mortality has 175 – These are summarised in fig 1. Endoscopic duct caculi. Am J Surg 1998; :10 3. not been reported. 4 Gilchrist A, Ross B, Thomas WE. extraction of common bile duct stones after Extracorporeal shockwave lithotripsy for spincterotomy and mechanical lithotripsy has Q2: What does the post-treatment common bile duct stones. Br J Surg a success rate of up to 95% and is considered ERCP film (fig1 in questions; see p 1997;84:29–32. the treatment of choice.12The reason for fail- 178) show? 5 Janssen J, Johanns W, Weickert U, et al. ure in this case was the large size of the bile At repeat ERCP the pigtail stent was removed Long term results after successful extracorporeal gallstone lithotripsy. Scand J duct calculus. Other reasons include bile duct and the cholangiogram shows no evidence of strictures, unusual anatomy, and calculi be- Gastroenterol 2001;36:314–7. calculi with satisfactory drainage from the Ellis RD yond reach of the wire basket.1–3 6 , Jenkins AP, Thompson RP, et al. common bile duct. Clearance of refractory bile duct stones with Traditionally such patients have been re- Spontaneous passage of calculi occurs in up exrtacorporeal shockwave lithotripsy. Gut ferred for surgical exploration of the common to 10% of patients, with 80% requiring removal 2000;47:728–31. bile duct but this procedure is not without of stone fragments during repeat ERCP.1 Al- 7 Lomanto D, Fiocca F, Nardovino M, et al. risk, particularly in elderly patients or those ESWL experience in the therapy of difficult 4 though recurrence of bile duct calculi is with major medical comorbidities. estimated at 14% after one year, most of these bile duct stones. Dig Dis Sci 1996;41:2397–403. Extracorporeal shock wave lithotripsy are amenable to endoscopic treatment.2 (ESWL) was investigated initially for treatment ESWL is an effective non-invasive treat- of gallbladder stones, but a high stone recur- ment modality that can be performed safely An unusual cause of rence rate has limited its use in this condition. 5 on an outpatient basis, without use of general In recent years high energy ESWL has been anaesthesia. For this reason it is a useful persistent vomiting used with more promising results in high risk treatment option in patients with difficult Q1: What abnormality is shown on the patients with common bile duct stones. common bile duct calculi who are considered In this case, given the patient’s age and to be poor candidates for surgery. barium meal (see p 178)? comorbidities it was decided that this was the An abnormal filling defect in close association treatment of choice. Biliary drainage was Final diagnosis with a thin C-shaped radio-opaque strip can achieved during initial ERCP using a pigtail Extracorporeal shock wave lithotripsy as a be seen in the gastric remnant (grey arrow). stent. treatment option for common bile duct Radio-opaque clips can also be seen around The patient then underwent one session of calculi. the cardia (white arrow). These appearances high energy ESWL, during which the calculus are in keeping with an Angelchik prosthesis was targeted by ultrasonography.12 Studies References which has become detached and eroded into have shown that between 20% and 50% of 1 Sackmann M, Holl J, Sauter GH, et al. the stomach. patients will require more than one treatment Extracorporeal shock wave lithotripsy for Q2: What are the options for dealing with this complication? Gastroscopy should be performed not only to confirm the diagnosis but also in an attempt to remove the prosthesis endoscopically.1 At http://pmj.bmj.com/ gastroscopy the stomach mucosa appeared normal and the silicon prosthesis, although covered with debris, was easily visualised. However, despite several attempts, it was not possible to retrieve the prosthesis endoscopi- cally. The only other option was to remove the prosthesis surgically and this was performed in this case by carrying out a laparotomy and gastrotomy. The patient made an uncompli- on September 27, 2021 by guest. Protected copyright. cated recovery and was free of symptoms at review three months later. Q3: What other complications have been reported after insertion of this prosthesis? The Angelchik prosthesis is no longer widely used because of the high incidence of compli- cations. Intractable dysphagia was common and often required removal of the prosthesis. Free extraluminal migration into the abdomi- nal cavity can occur. The prosthesis usually comes to rest in the pelvis and is usually manifested by chronic lower abdominal pain or urinary symptoms. Migration into the mediastium and distal slippage has also been reported. Erosion of the prosthesis into the oesophagus can lead to abscess formation and intraluminal erosion may even progress to cause small bowel obstruction. Discussion In 1979, Angelchik and Cohen reported a series of 46 patients who had reflux oesophagitis Figure 1 Treatment options for common bile duct stones (CBD, common bile duct; ERCP, treated surgically with the insertion of an endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shockwave incomplete “doughnut” shaped ring of silicon lithotripsy). around the gastro-oesophageal junction: the www.postgradmedj.com 182 Self assessment answers Angelchik prosthesis. The C-shaped ring was relieved by rest. The pain is usually localised to Final diagnosis Postgrad Med J: first published as 10.1136/pmj.79.929.181 on 1 March 2003. Downloaded from tied around the lower oesophagus with Dacron the groin, inner thigh, or knee region. On Legg-Calvé-Perthes disease. straps. Insertion of this prosthesis was quick, examination, these children will have a simple to perform, and standardised and it was positive Trendelenburg test and have limited References hoped that it would become superior to the abduction and difficulty medially rotating 1 Pokharel RK. Children with Legg-Perthes other surgical antireflux procedures available their affected leg. Often, they also have trouble diseases. Clin Orthop 1999;363:268–9. at the time which were all technically difficult, with hip motion. With disease progression, 2 Leet AI. Evaluation of the acutely limping time consuming, and had variable results necrosis of the femoral head leads to further child. Am Fam Physician 2000;64:1011–8. Hubbard AM which were operator dependent.2 degeneration and immobilisation of the hip, 3 . Imaging of pediatric hip which can then progress to disuse atrophy of disorders. Radiol Clin North Am The early short term results for the prosthe- 39 – the buttocks, thigh, and calf muscles.1 2001; :721 32. sis were promising, and objective and subjec- 4 Roy DR. Current concepts in tive outcome measures were similar to other Q2: What are alternative differential Legg-Calve-Perthes disease. Pediatr Ann accepted surgical antireflux procedures.3 1999;28:748–52. However the initial enthusiasm has been diagnoses in a child with a limp? tempered with experience and when more The differential diagnosis list for a child with long term results were analysed up to 20% of a limp is quite extensive and can include vari- Middle aged man with prostheses had to be removed for intractable ous hormonal, metabolic, orthopaedic, and groin pain dysphagia and there were other reports of genetic causes. Frequent causes of limp also vary by age group. In the 4–11 year old age significant problems due to migration and Q1: What abnormality is shown and 45 group, the most common causes of a limping erosion of the prosthesis. what is the diagnosis? The prosthesis has a tantulum radio- gait are: septic arthritis, osteomyelitis, tarsal coalition, transient monoarticular synovitis, We can see a contrast filled oblong sac on the opaque marker encircling its periphery and left inguinal region (fig 1; see p 179). This is radio-opaque clips were frequently used to juvenile rheumatoid arthritis, LCP, slipped capital femoral epiphysis, and neoplasias such herniation of the bladder in forming the wall reinforce the knot in the tied Dacron straps 12 as osteoid osteomas or osteochondromas.2 of the direct inguinal hernia. making it possible to identify the prosthesis Many of these common causes can be on radiological images as seen in this case. diagnosed by laboratory evaluation such as Q2: How do you manage this The continued use of the Angelchik pros- erythrocyte sedimentation rate for transient problem? thesis was abandoned in most centres over 10 monoarticular synovitis, rheumatoid factor The management of this condition is in two years ago but at least 25 000 have been and antinuclear antibody testing for juvenile parts: inserted worldwide. In this case erosion rheumatoid arthritis, and presence of a febrile (A) Repair of the inguinal hernia, which is occurred 14 years after insertion, longer than course for septic arthritis or osteomyelitis. the main cause of the pain, using a form of any other case reported. The presentation of wire mesh to reinforce the posterior wall of new gastrointestinal symptoms should still Discussion the inguinal canal to prevent recurrence of the today arouse suspicion in a patient known to Epidemiologically, LCP disease has been shown hernia.1 have an Angelchik prosthesis.