To evaluate the incidence and symptoms of and risk factors for biliary sludge and gallstones during pregnancy and to assess the natural history of these conditions in the first year after delivery. Cohort study. A total of 272 pregnant women recruited in the first trimester. Biliary sludge and gallstones were diagnosed using ultrasonography, both during pregnancy and after delivery. Predictors of the presence or disappearance of sludge and stones were examined. Overall, from the first trimester of pregnancy until the immediate postpartum period, 67 women were newly diagnosed with biliary sludge, and 6 women were newly diagnosed with gallstones. The respective incidence rates were 31% (95% Cl, 25% to 37%) and 2% (95% Cl, 0.2% to 4%). During pregnancy, 28% of women experienced biliary pain, which was associated only with presence of stones. After delivery, 92 women had sludge and 23 had stones. Sludge disappeared in 61% of these women (Cl, 50% to 73%) after a mean follow-up of 5 months, and stones disappeared in 28% of women (Cl, 10% to 46%) after 9.7 months of follow-up. Biliary sludge occurred frequently during pregnancy but was generally asymptomatic and often disappeared spontaneously after delivery. Gallstones were much less frequent and were more likely to be associated with biliary pain.

This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.

PURPOSE The aim of this study was to evaluate the analgesic and adverse effects and the doses of methadone in comparison to morphine. PATIENTS AND METHODS A prospective randomized study was performed in a sample of 40 patients with advanced cancer who required strong opioids for their pain management. Patients were treated with sustained-release morphine or methadone in doses titrated against the effect administered two or three times daily according to clinical need. Opioid doses, adjuvant medications, symptoms associated with opioid therapy, pain intensity, and pain mechanisms were recorded. The opioid escalation indices in percentage (OEI%) and milligrams (OEImg) were calculated. The effective analgesic score (EAS) that monitors the analgesic consumption-pain ratio was also calculated at fixed weekly intervals. RESULTS differences in pain intensity were found. Patients treated with methadone reported values of OEI significantly less than those observed in patients treated with morphine. Seven patients in the methadone group maintained the same initial dosage until death, whereas only one patient in the morphine group did not require opioid dose escalation. A more stable analgesia in time in patients treated with methadone was shown by the low number of gaps in EASs reported. Symptom frequencies and intensities were similar in the two groups. CONCLUSION Methadone is a drug of indisputable value in the treatment of cancer pain, and an unbalanced focus on the risks of inappropriate use rather than the benefits should not compromise the use of a relevant alternative to morphine in the management of cancer pain.

Endoscopic retrograde cholangiopancreatography (ERCP) is the most appropriate technique to treat common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Biliary and/or pancreatic duct cannulation and visualization are successful with ERCP in a high percentage of cases managed by experienced hands [ 1 ] [ 2 ] [ 3 ]. Common causes of failure include complex peripapillary diverticula, prior surgery procedures such as gastrectomy with Billroth II anastomosis, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones [ 4 ]. Percutaneous transhepatic cholangiography (PTC) [ 5 ] and surgery are the alternative approaches to access and drain obstructed ducts. The development of the large channel linear array echoendoscope allows for therapeutic procedures such as fine needle aspiration (FNA) and biopsy [ 6 ], celiac plexus neurolysis [ 7 ], pancreatic pseudocyst [ 8 ], and perirectal and retroperitoneal abscess drainage [ 9 ]. Since 1996 when Wiersema et al. first described endoscopic ultrasound (EUS)-guided bile duct puncture [ 10 ], several case reports have been published on EUS-guided biliary and pancreatic duct puncture and drainage [ 11 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ] [ 19 ]. These case reports illustrate different techniques to approach bile and pancreatic ducts: transgastric or transduodenal puncture, rendezvous after positioning a guide wire through the papilla, or creating a new papilla by fistula formation. In all of these reports, interventional EUS proved feasible and safe with a low rate of complications, but only few series have been published. Kahaleh et al. have recently described a series of 23 patients treated with interventional endoscopic ultrasound cholangiography (IEUC). Biliary decompression was accomplished in more than 90 % of the cases that had previously received ERCP without success; in one of these cases, bile leakage occurred using the extrahepatic approach [ 20 ]. We describe a series of consecutive patients in whom ERCP failed for different reasons ([ Table 1 ]), and IEUC was applied instead of the traditional percutaneous approach.