This prospective and randomized trial sought to compare large-bore plastic endoprostheses (14 French) and self-expanding metal stents (24 French) in the palliative treatment of obstructive jaundice due to biliary hilar malignancies. Twenty patients with Type II-IV (Bismuth classification) hilar obstruction were randomized to treatment with either plastic or metal stents. Both treatment groups were well matched with regard to all assessed clinical criteria before stenting. Stent placement was uniformly successful in the metal group and in 88.9% of the plastic group. Early stent failure (< 30 days) occurred in two patients of the plastic stent group. Longterm (> 30 days), stent failure was observed in 50% of the plastic group and 18.2% of the metal stent group. All differences were not statistically significant. The number of re-interventions required to manage stent-related problems proved to be significantly higher in the plastic group (2.4 +/- 2.6) compared to the metal group (0.4 +/- 0.5). Hospitalization for treatment of stent complications was also significantly higher in the plastic treatment group. The costs calculated for stents and hospital stay for required re-interventions were therefore higher in the plastic stent group. In conclusion, metal stent insertion for palliation of hilar malignancies does not only offer higher success rates and higher patency rates compared to plastic stent insertion, but is also cost-effective since patients require fewer re-interventions.

No abstract

The overwhelming majority of existing data suggest that early endoscopy is safe and effective for all risk groups. The clinical and economic outcomes of early endoscopy should be confirmed in additional well-designed randomized controlled trials. Given the strength of the evidence, efforts to develop a more standardized and time-sensitive approach to acute nonvariceal upper gastrointestinal tract hemorrhage should be undertaken.

A 35-year-old woman presents with a 6-month history of lower gastrointestinal tract symptoms. She describes lower abdominal discomfort along with a longstanding fluctuating bowel habit, such that her stools often occur more frequently and with looser consistency. In addition, she experiences a sense of incomplete evacuation after defecation. She specifically denies any weight loss or the passage of blood or mucus per rectum. Her symptoms are unrelated to menstruation. She has always been healthy and is not taking any regular prescribed or over-the-counter medications. Her father was diagnosed with colorectal carcinoma at age 80 years. You notice that she is thin but without pallor. Her abdomen is soft and nontender, without palpable organomegaly or masses. Results of a digital rectal examination are normal. Complete blood cell count CME available online at www.jamaarchivescme.com and questions on p 1828.

When HIV-infected patients are exposed to cryptosporidium, those with CD4 counts < or = 50 per cubic millimeter are at increased risk for biliary symptoms and for death within one year after the infection.