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Periportal fibrosis and the liver ultrasonography findings in vinyl chloride workers arthritis medication on tv buy cheap meloxicam 15 mg line. Elevated serum hyaluronic acid may identify vinyl chloride workers at high risk for the subsequent development of hepatic angiosarcoma. Serum cytokeratin 18 and cytokine elevations suggest a high prevalence of occupational liver disease in highly exposed elastomer/ polymer workers. Toxicity due to 2- and 13-wk inhalation exposures of rats and mice to N,Ndimethylformamide. Liver function alterations in synthetic leather workers exposed to dimethylformamide. Abnormal liver function associated with occupational exposure to dimethylformamide and hepatitis B virus. Outcome of sixty four cases of ethylene bromide ingestion treated in a tertiary care hospital. Viral infections and chemical exposures as risk factors for hepatocellular carcinoma in Vietnam. Biochemical and molecular mechanisms of N-acetyl cysteine and silymarinmediated protection against maneb- and paraquat-induced hepatotoxicity in rats. Ultrastructural, protein, and lipid changes in liver associated with chlordecone treatment of mice. Anthropogenic sources of arsenic and copper to sediments in a suburban lake, Northern Virginia. Chronic arsenic toxicity: Clinical features, epidemiology, and treatment: Experience in West Bengal. Increased serum level of epidermal growth factor receptor in liver cancer patients and its association with exposure to arsenic. Chronic arsenic poisoning in the rat: Treatment with combined administration of succimers and an antioxidant. Iron poisoning: A literature-based review of epidemiology, diagnosis, and management. Long-term safety and effectiveness of iron-chelation therapy with deferiprone for thalassemia major. Lack of progressive hepatic fibrosis during long-term therapy with deferiprone in subjects with transfusion-dependent beta-thalassemia. Long incubation period for the induction of cancer by thorotrast is attributed to the uneven irradiation of liver cells at the microscopic level. Pathomorphologic characteristics of 102 cases of Thorotrast-related hepatocellular carcinoma, cholangiocarcinoma and hepatic angiosarcoma.

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These locations correlate with the clinical complications associated with each species arthritis wrist exercises purchase meloxicam 7.5 mg line. The eggs are deposited in the terminal venules and eventually migrate into the lumen of the involved organ, after which they are expelled in the stool or urine. Excreted eggs hatch immediately in fresh water and liberate early intermediate miracidia that infect their snail hosts. The miracidia transform into cercariae within the snails and then Trichinosis Humans may be infected with Trichinella spiralis by eating raw or undercooked pork bearing larvae, which are released in the small intestine, penetrate the mucosa, and disseminate through the systemic circulation. Larvae can be found in the myocardium, cerebrospinal fluid, brain, and, less commonly, liver and gallbladder. The larvae then reenter the circulation and reach striated muscle, where they become encapsulated. Clinical manifestations occur when the worm burden is high and include diarrhea, fever, myalgias, periorbital edema, and leukocytosis with marked eosinophilia. Rarely, larvae can be seen invading hepatic sinusoids on examination of a liver biopsy specimen. The diagnosis is suggested by a characteristic history in a patient with fever and eosinophilia. Serologic assays for antibody to Trichinella may not be helpful in the acute phase of infection but can be useful after 2 weeks. A, Liver resection specimen demonstrating characteristic pipestem fibrosis due to long-term infection with Schistosoma mansoni. Acute toxemic schistosomiasis (Katayama syndrome or Katayama fever), presumably a consequence of the host immunologic response to mature worms and eggs, occurs approximately 4 to 6 weeks after exposure. Manifestations include headache, fever, chills, cough, diarrhea, myalgias, arthralgias, tender hepatomegaly, and eosinophilia. Mesenteric infection leads to hepatic complications, including periportal fibrosis, presinusoidal occlusion, and, ultimately, portal hypertension, as a result of the inflammatory reaction to eggs deposited in the liver. Chronic schistosomal infection may be complicated by increased susceptibility to Salmonella infections. Results of liver biochemical tests generally are normal until the disease is at an advanced stage. The possibility of acute schistosomiasis should be considered in a patient with a history of exposure, abdominal pain, diarrhea, and fever. Multiple stool examinations for ova may be required to confirm the diagnosis because results frequently are negative in the early phase of disease.

Diseases

• Crane Heise syndrome
• McDonough syndrome
• Protein energy malnutrition
• Acute lymphoblastic leukemia congenital sporadic aniridia
• Nystagmus with congenital zonular cataract
• Amaurosis congenita of Leber
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Liver transplantation should be considered in all patients with cirrhosis and variceal bleeding (see Chapter 97) define arthritis deformans cheap meloxicam 15 mg online. Selective Shunts the most widely used selective shunt is the distal splenorenal shunt, originally described by Warren and colleagues. The entire length of the pancreas must be mobilized, and the left adrenal vein must be ligated. The distal splenorenal shunt has been associated with control of variceal bleeding in approximately 90% of patients and a lower rate of hepatic encephalopathy than that reported for total shunts. The portal system is thus disconnected from the azygos system so that all flow from the gastroesophageal junction is through the short gastric veins into the splenic vein. The splenic vein is then anastomosed to the left renal vein in an end-to-side fashion. Partial Portosystemic Shunts A partial portosystemic shunt is carried out using a synthetic interposition graft between the portal vein and the inferior vena cava. When the shunt diameter is 8 mm, portal pressure is reduced below 12 mm Hg, and antegrade flow to the liver is maintained in most patients. As in patients who have had a distal splenorenal shunt, ascites may occur in approximately 20% of patients who have had a partial portosystemic shunt, because hepatic sinusoidal pressure is not reduced. Nevertheless, surgical portacaval shunts should be avoided in patients who are potential candidates for liver transplantation. With this procedure, portal blood flow is restored to the liver, thereby reducing the risk of hepatic encephalopathy or longterm learning disability in children. A jugular vein graft may be used to bridge the superior mesenteric vein to the intrahepatic portion of the left portal vein in the Rex recessus. A shunt with a diameter less than 12 mm is created with an interposition graft, or alternatively a direct vein-to-vein anastomosis may be constructed. Variceal bleeding, as well as ascites, is well controlled because the hepatic sinusoids are decompressed. Variceal rebleeding following a total shunt is seen in less than 10% of patients, but hepatic encephalopathy occurs in 30% to 40% of patients. In patients with small varices at initial endoscopy, progression to large varices occurs at a rate of about 10% per year and is related predominantly to the degree of liver dysfunction. The risk of bleeding in patients with varices less than 5 mm in diameter is 7% by 2 years, and the risk in patients with varices greater than 5 mm in diameter is 30% by 2 years.

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Carboxypeptidase A cleaves aromatic amino acids rheumatoid arthritis diet mercola order meloxicam line, while carboxypeptidase B cleaves arginine or lysine peptides from the carboxy terminal end of proteins and peptides. The final products of intraluminal digestion thus are produced by cooperative activity of endo- and exopeptidases and consist of a number of neutral and basic amino acids together with peptides of 2 to 8 amino acids in length. About 30% of luminal amino nitrogen is found in amino acids and about 70% in oligopeptides. In the 1970s, however, studies revealed that small peptides of 2 and 3 amino acids in length. Pepsins are a family of endoproteases that hydrolyze internal peptide bonds in proteins. They act preferentially on peptide bonds that are formed by the aromatic amino acids phenylalanine and tyrosine, and by the branched-chain amino acid leucine. There are 2 immunologically distinct groups of pepsins (groups 1 and 2), although 8 fractions are identified electrophoretically. Enterokinase (enteropeptidase) plays a critical role in activating trypsinogen to form trypsin. Trypsin in turn activates not only more trypsinogen but also other proteolytic enzyme precursors. Patients with cystinuria and Hartnup disease, who have specific defects in the absorption of basic and neutral amino acids, respectively, do not develop protein-deficiency states, because the absorption of peptides in these patients is normal. A range of peptidases are present on the brush border and in the cytoplasm of villus epithelial cells, in contrast to oligosaccharidases, which are found only at the brush border (Table 102-5). These peptidases account for the hydrolysis of oligopeptides up to about 8 amino acid residues in length. Cytoplasmic enzymes are much more heat labile than those in the brush border, and there are differences in the electrophoretic mobility patterns for the 2 sets of enzymes. The chain length of the peptides is an important factor that determines not only whether the site at which hydrolysis occurs is at the brush border or within the cell but also its rate. Aminopeptidase A has specificity for peptides with acidic amino acids at their amino terminus. Aminopeptidases 1 and 3 (distinguished on electrophoretic mobility) have specificities for different substrates with different amino acid peptide bonds. Folate conjugase, an enzyme concerned with hydrolysis of dietary folate, will be considered later. These membranebound peptidases produce the most absorbable products of protein hydrolysis, including amino acids, dipeptides, and tripeptides. Although these peptidases are active throughout the small intestine, they appear to be most active in the ileum. Other characteristics of a tripeptide that are required for rapid hydrolysis include a free alpha amino group, an alpha carboxyl group, and an L-configuration for the 2 amino acid residues.

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Excluding patients carrying this polymorphism has practically abolished the risk of hypersensitivity reactions to abacavir (0% vs arthritis youtube 7.5 mg meloxicam buy. The onset is a median of 6 months (range, 3 to 17 months) after treatment is started. The often nonspecific symptoms include nausea, vomiting, diarrhea, dyspnea, lethargy, and abdominal pain. Extrahepatic manifestations, such as myopathy or peripheral neuropathy, and in severe cases pancreatitis and renal failure, may follow the onset of the lactic acidosis and liver injury. Any new aminotransferase elevation should be followed immediately by measurement of serum lactate, muscle, and pancreatic enzyme levels. The majority (>75%) of those affected have been men who had already achieved virologic suppression and had been exposed to these agents for a period of 13 to 111 months. Nodular regenerative hyperplasia and portal vein thrombosis are the main histologic lesions. Postulated mechanisms include sinusoidal endothelial cell injury and thrombophilia. Most cases of aspirininduced hepatotoxicity have been identified by biochemical testing, rather than clinical features. If present, symptoms usually begin within the first few days or weeks of high-dose aspirin therapy. Resolution occurs rapidly after drug withdrawal, and salicylates can be reintroduced at a lower dose. All salicylates appear to carry hepatotoxic potential, so there is no advantage to replacing aspirin with another salicylate. Liver biopsy specimens reveal a nonspecific focal hepatitis with hepatocellular degeneration and hydropic changes. It is characterized by acute encephalopathy and hepatic injury, the latter documented by a 3-fold or greater rise in serum aminotransferase or ammonia levels and by characteristic histologic findings. Clinical and laboratory features of chronic liver disease do not develop in affected persons, and features of drug allergy are not present. Management requires suspecting the correct diagnosis and reducing the dose (or discontinuation) of aspirin. Non-nucleoside Reverse Transcriptase Inhibitors Non-nucleoside reverse transcriptase inhibitors occasionally cause hepatitis as part of a hypersensitivity reaction within the first 6 weeks of use. The recommended 2-week dose escalation regimen was not adhered to in some of the cases. The latter also may be associated with unconjugated hyperbilirubinemia in 7% of treated persons, a finding that is of no clinical consequence (see Chapter 21). The association with peripheral or tissue (in liver biopsy specimens) eosinophilia in some cases suggests an immunoallergic basis for liver injury. Liver injury is associated with high (>400 mg/ day) ritonavir doses but not with regimens that include lowdose ritonavir. The course of the illness is generally mild, and the liver injury responds favorably to drug withdrawal.

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It is no longer used for prophylaxis but is widely used in Africa in combination with artesunate severe arthritis in dogs knee purchase meloxicam 15 mg mastercard. Amodiaquine should be reserved for cases of chloroquine-resistant falciparum malaria, and dose recommendations should be strictly observed. Hycanthone, an antischistosomal agent, caused dosedependent hepatotoxicity when used in the past. Risk factors for hepatotoxicity included concomitant administration of phenothiazines or estrogens, preexisting liver injury, and bacterial infection. More severe lesions include zonal and bridging necrosis or massive (panlobular) hepatic necrosis; these lesions may be associated with acute (fulminant or subfulminant) hepatic failure. Partial dose dependence, a relationship between hepatitis and metabolism of the drug, and histologic or ultrastructural features consistent with chemical toxicity are often found. The clinical and laboratory features that suggest one or the other type of drug hepatitis are summarized in Table 88-6. Nitrofurantoin is discussed as an example of immunoallergy, and isoniazid is used to illustrate metabolic idiosyncrasy. Other relatively frequent examples of drug hepatitis are described briefly, including those associated with granulomatous reactions and chronic hepatitis. Immunoallergic Reactions Nitrofurantoin Nitrofurantoin is a urinary antiseptic agent that has long been associated with hepatic injury. Two thirds of acute cases occur in women, and the female-to-male ratio is 8: 1 for chronic hepatitis. Chronicity depends mostly on the duration of drug ingestion, which has been less than 6 weeks in acute cases but more than 6 months in 90% of chronic cases. Immunoallergic Reaction <1 case per 10,000 persons exposed Women, often 2: 1 Fairly constant, 2-10 weeks None None Prompt improvement (rare exceptions [e. The mortality rate for chronic nitrofurantoin hepatitis is 20%, compared with 5% to 10% for acute hepatitis. Pneumonitis, which may be complicated by pulmonary fibrosis, can develop concurrently with hepatitis in 20% of cases and is suggested by cough and dyspnea. Serum bilirubin levels tend to be increased in proportion to the severity of the reaction. In contrast to most types of acute drug hepatitis, serum albumin concentrations often are low. Hypergammaglobulinemia is more likely in patients with chronic hepatitis than in those with acute hepatitis. Autoantibodies (antinuclear antibodies and smooth muscle antibodies) are present in some patients with acute hepatitis and in 80% of those with chronic hepatitis. Glucocorticoids have no role, even in patients with chronic hepatitis with autoimmune features. Monitoring liver biochemical tests in users of nitrofurantoin is unlikely to be useful or cost effective. This finding implicates a possible metabolic factor in the pathogenesis of phenytoin toxicity.

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Usually rheumatoid arthritis and stress order cheap meloxicam, they are located in the extrahepatic biliary tract, particularly at the junction of the cystic duct and the bile duct. In contrast to the other biliary malignancies, however, 77% to 93% of ampullary carcinomas are resectable at the time of diagnosis. Outcomes are good in the absence of lymph node metastases, with 5-year survival rates of 59% to 78%. They are considered premalignant because of their potential to transform into cystadenocarcinomas; hence, the treatment of choice is complete resection. Cystadenocarcinomas can be distinguished morphologically from cholangiocarcinomas by their cystic character. Embryonal rhabdomyosarcoma of the biliary tract is extremely rare in adults but is the most common malignant tumor at this anatomic location in children. The prognosis of biliary rhabdosarcomas is good, with reported 5-year survival rates of up to 78%. Lymphangiomas are often asymptomatic and detected incidentally; however, they can increase in size and result in abdominal pain or jaundice. Usually, lymphangiomas manifest as a multilocular, fluidfilled, cystic mass with thin walls and septa and show enhanced signal density with administration of a contrast agent. Tumors of the ampulla of Vater: Histopathologic classification and predictors of survival. Clinicopathologic analysis of ampullary neoplasms in 450 patients: Implications for surgical strategy and long-term prognosis. Guidelines for the management of biliary tract and ampullary carcinomas: Surgical treatment. Genomic and genetic characterization of cholangiocarcinoma identifies therapeutic targets for tyrosine kinase inhibitors. Incidence and risk factors for cholangiocarcinoma in primary sclerosing cholangitis. Intrahepatic cholangiocarcinoma and hepatolithiasis: An unusual association in Western countries. Late development of bile duct cancer in patients who had biliary-enteric drainage for benign disease: A follow-up study of more than 1,000 patients. Risk factors for intrahepatic and extrahepatic cholangiocarcinoma: A hospital-based case-control study.

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Based on similar principles arthritis pain relief medication discount 7.5 mg meloxicam amex, the spatial resolution of measurements is also an important parameter to consider if relationships between motor events and intraluminal flow(s) are to be defined. Direct evaluation of small intestinal motility requires methods of measurement with a time resolution of at least 2 seconds so that contractions can be recognized as separate from one another, rather than as continuous or as an increase in basal pressure. In humans, the intrinsic frequency of duodenal contractions is up to 12 per minute. The optimal spatial resolution for studies of small intestinal motor function has not been determined, but the spatial patterning of pressures is known to vary over relatively small distances,49 with most propagating pressure wave sequences travelling less than 6 cm. Because of practical limitations of data handling and the number of sensors one can place in the small intestine, measurement techniques usually either achieve high temporospatial resolution over a short distance or low temporospatial resolution over a far greater distance. Realistically this means that data gained from different studies are usually interpreted alongside one another to provide more complete information. Intracellular recordings of electrical potential can be obtained from a number of cell types within the small intestine and its extrinsic neural control system. These recordings give detailed information about the signals received and transmitted by individual cells, with excellent temporal resolution, but generally they cannot be applied concurrently over a significant length of intestine and therefore have limited real-time spatial resolution with regard to motor events. A combined functional and neuroanatomic approach whereby imaging of specific neurons with intracellular or extracellular recordings and chemical coding using immunohistochemistry are performed concurrently has allowed important correlations to be made between structure and function. Multichannel manometric recordings of the human antrum and duodenum, with recording points placed at varied intervals: 1. These data demonstrate some of the limitations of varying the interval between recording points: As a phasic contraction travels along a section of intestine, the associated rise in pressure is detected only at each measurement point. If the interval between recording points is too wide, unrelated pressures may be judged to be related to the propagated pressure wave, or a propagated pressure wave sequence may be judged to be a limited phasic event. Although such single-cell techniques generally have been applied to animal tissues, the results also probably apply to humans, because a similar structural organization of control elements is seen in human tissue. Recording of Muscle Contractions Increased muscle tension generally is directly recorded with strain gauges; these can be used in muscle strips, isolated loops of intestine, and whole-organ preparations or even chronically implanted in animals. Over short lengths of intestine, a spatial resolution of approximately 1 cm is possible. Unfortunately, strain gauges are not suitable for use in human subjects, although they have provided much valuable information on the organization of motor events in animals. One such approach is fluorescence measurement of calcium transients (rapid increases in free intracellular calcium) in smooth muscle. Other measurement techniques that record phenomena resulting from contractions of smooth muscle include luminal manometry (reflecting intraluminal pressure increases), fluoroscopy (showing wall movement and movement of intraluminal contrast), and transit studies performed by a number of approaches.

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If endoscopic and pharmacologic therapies fail to control gastric variceal bleeding arthritis in dogs human medication purchase meloxicam with mastercard, then a Linton-Nachlas tube may be passed as a temporizing measure. Two studies performed in patients with good liver function, most of whom had extrahepatic portal vein thrombosis, demonstrated excellent results, with a low longterm risk of bleeding and encephalopathy, after creation of a surgical shunt. Ectopic Varices Varices that occur at a site other than the gastroesophageal junction are termed ectopic varices and account for less than 5% of all varix-related bleeding episodes. They also may manifest with hemobilia, hematuria, hemoperitoneum, or retroperitoneal bleeding. The duodenum is a common site of ectopic varices, and varices typically are associated with portal vein obstruction, but in the West, the usual cause of duodenal varices is cirrhosis. The common occurrence of duodenal varices in patients with portal vein obstruction probably relates to the formation of collateral vessels around the thrombosed portal vein that connect pancreaticoduodenal veins to retroduodenal veins, which drain into the inferior vena cava. They are recognized by a bluish halo surrounding the stoma and by a dusky appearance and friable consistency of the stomal tissue; no obvious variceal lesions are seen. Rectal varices are dilated superior and middle hemorrhoidal veins, whereas hemorrhoids are dilated vascular channels above the dentate line. The diagnosis of intra-abdominal Management In patients suspected of having ectopic variceal bleeding, vasoactive drugs may be administered initially to control the bleeding. If the bleeding ectopic varix is visualized at endoscopy, as typically is the case with duodenal or colonic varices, then endoscopic therapy can be carried out. Colonic varices tend to be larger in diameter and may require application of hemostatic clips. Patients with bleeding stomal varices can be trained to compress the site locally if bleeding is obvious. Because bleeding from stomal varices is visible and detected early, the mortality rate for bleeding stomal varices is low. At present, no recommendations support primary prophylaxis to prevent bleeding from ectopic varices. To prevent rebleeding from ectopic varices, pharmacologic treatment with a beta blocker is usually tried, although no studies are available to support this approach. Embolization of varices using a transhepatic approach can control bleeding in most patients with stomal varices. Placement of a nonselective portosystemic shunt, such as a portacaval shunt, mesocaval shunt, or proximal splenorenal shunt, should be carried out in a patient with stomal varices. Patients with ectopic varices who present with intraperitoneal hemorrhage have a poor outcome because the diagnosis usually is not considered and is often made at laparotomy. Acute bleeding may be controlled by transhepatic obliteration or surgical ligation of the varices.

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Salivary arthritis questions and answers order meloxicam 7.5 mg on-line, gastric, biliary, pancreatic, and intestinal secretions make up most of this amount. The bulk of this fluid is absorbed in the small intestine, and approximately 1500 mL cross the ileocecal valve. The colon efficiently reabsorbs most of this fluid, with only 100 to 200 mL lost in stool. Permeability can be viewed as a surrogate to conductance, which is a reciprocal of resistance. Permeability of the intestinal epithelium decreases down the length of the cephalocaudal axis, the distal colon having a relatively tight epithelium. Absorptive mechanisms differ in each segment of the intestine; chloride secretion is found throughout the intestine. In the large intestine, the spatial separation of crypts and surface cells allows efficient reabsorption of fluid. The overall architecture of the intestinal musculature influences bulk fluid flow and transit time via changes in motility patterns (see Chapters 99 and 100), but the work of fluid transport occurs in the epithelia. They act as the first line of defense between the mucosal (luminal) and serosal (blood-side) compartments and are capable of bulk transport of fluid from 1 compartment to the other. One fundamental property of epithelia is cellular polarity, with molecularly distinct apical (luminal) and basolateral (serosal) membranes demarcated by intercellular tight junctions. A loss of tight junction integrity disrupts the barrier function and vectorial transport capabilities of the tissue. This basic cell model is modified by insertion of transporters into either the apical or basolateral membrane or by the characteristics of tight junctions that determine the unique qualities of a specific epithelial segment. A complex interaction of protein-sorting signals, cytoskeletal elements, and intracellular trafficking processes determines whether a newly synthesized protein is targeted to either the apical or basolateral membrane. In contrast, other proteins can insert randomly into either an apical or basolateral domain, but they may be retained in the basolateral pole by specific components like ankyrin. When tight junctions are disrupted in vitro, diffusion and intermingling of apical and basolateral proteins in the fluid phase of the membrane result in a loss of epithelial cell polarity. Intestinal epithelial cells are structurally and functionally geared for vectorial transport. The cell membrane is divided into distinct apical and basolateral domains by the tight junctions. Depending on the tissue, the apical membrane can have a more or less prominent brush border appearance due to the presence of numerous microvilli.

Chenor, 25 years: This lack of specific criteria reflects the limited understanding of the relationship between small intestinal intraluminal time-space pressure patterning and the achievement of mixing and propulsion within the small intestine.

Gelford, 31 years: A randomized unblended pilot study comparing albumin versus hydroxyethyl starch in spontaneous bacterial peritonitis.

Mezir, 41 years: The liver provides energy continuously to the entire body through its ability to store and modulate the availability of systemic nutrients.

Vak, 34 years: We are delighted to welcome many new authors, as well as returning authors, to the tenth edition.

Domenik, 61 years: The epidemiology and natural history of primary biliary cirrhosis: A nationwide population-based study.

Jared, 35 years: This complex interplay of transporters is an elegant demonstration of cellular economy.

Tjalf, 57 years: Acebutolol, carvedilol, labetalol, and metoprolol have each been associated with cases of acute hepatitis, some of which were severe; some cases were proved by rechallenge.

Raid, 24 years: Newer pathogenetic concepts in cholesterol gallstone formation: A unitary hypothesis.

Faesul, 44 years: Hepatitis B virus and hepatitis delta virus genotypes in outbreaks of fulminant hepatitis (Labrea black fever) in the western Brazilian Amazon region.

Lisk, 30 years: Classic histologic features of alcoholic hepatitis include ballooning degeneration of hepatocytes, alcoholic hyaline (Mallory-Denk bodies) within damaged hepatocytes, and a surrounding infiltrate composed of polymorphonuclear leukocytes.

Rendell, 58 years: The parenchymal portion of the portal and hepatic venous systems consists of minute side branches that originate as orderly rows along the terminal branches of the conducting portion.

Giores, 62 years: The onset of these symptoms is typically insidious, although an acute hepatitis-like presentation has been described.

Ashton, 50 years: Liver biopsy should be repeated before initiating more intensive therapy to confirm lack of a histologic response and to exclude other important causes of graft dysfunction, such as ischemia.

Milten, 36 years: Recent advances in fiberoptic technology have made it possible to record high-resolution pressure profiles throughout the entire length of the colon.

Ismael, 37 years: Endoscopic palliation of patients with biliary obstruction caused by nonresectable hilar cholangiocarcinoma: Efficacy of self-expandable metallic Wallstents.