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Acute liver failure (ALF)-related encephalopathy was previously characterized by MR spectroscopy of single voxels containing both grey and white matter brain tissue. Quantitative multivoxel MRS was used here to compare grey and white matter brain tissue concentrations of glutamate/glutamine (Glx) and lactate in ALF and associate the results with other liver function parameters. Five pediatric patients with ALF-related encephalopathy and five controls, examined after successful liver transplantation, were examined by brain MRI/MRS. ALF patients had higher Glx and lactate concentrations in brain white matter than controls (Glx + 125%: P < 0.01; lactate + 33%, P < 0.05) and higher Glx in grey matter (Glx + 125%: P < 0.01). Within the group of ALF patients positive correlations were found between grey or white matter lactate concentration and serum ammonia (P < 0.05), and negative correlations between grey or white matter Glx and venous pH (P < 0.001). This is the first study presenting evidence of high Glx levels in both white and grey matter brain tissue in ALF-related encephalopathy. The elevations in CNS Glx and lactate concentrations appear to relate to hepatic detoxification (ammonia, venous pH), rather than to liver parenchymal integrity (aspartate aminotransferase, alanine aminotransferase) or biliary cholestasis (bilirubin, gamma-glutamyl transpeptidase, alkaline phosphatase). [ABSTRACT FROM AUTHOR]

The use of the double balloon endoscope for ERCP in patients with surgically altered anatomy has shown to be safe and feasible. This technique permits a variety of diagnostic and therapeutic possibilities. A case is presented of a 38-year old male, admitted with jaundice, 8 months after surgery for a malignant liver tumour with construction of a Roux-en-Y hepaticojejunostomy. A stenosis at the site of the biliodigestive anastomosis was diagnosed. Combining double balloon endoscopy with a percutaneous approach in a rendezvous procedure, it was possible to place a self-expandable biliary metal stent. This is the first report of a successful placement of a metallic stent using this technique.