A patient with choledocholithiasis--no therapy without risk

A 73-year-old man was admitted to the hospital because of recurrent fever and intermittent cholestasis. A cholecystectomy with hepatico-duodenostomy was performed ten years ago because of acute cholecystitis and impacted bile duct stones. Recurrent episodes of cholangitis occurred postoperatively and ERCP showed shrinkage of the hepatico-duodenal anastomosis with sump syndrome and recurrent bile duct stones. Endoscopic sphincterotomy for the improvement of bile flow was considered too dangerous at this time-point because of unfavourable intraduodenal position of the papilla Vateri. The patient refused reoperation. During the present hospitalization, endoscopic sphincterotomy and gallstone removal were performed. Within hours after intervention, necrotizing pancreatitis developed which could be managed without operation. No further episodes of cholangitis reoccurred after discharge from hospital. This case report demonstrates the risks of bile duct surgery and endoscopic sphincterotomy.     

Ultrastructure of the glial cells after spinal cord compression in rabbits

Sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by gastrointestinal debris after choledochoduodenostomy, resulting in cholangitis or, less commonly pancreatitis. Obstruction of the biliary tree by gastrointestinal contents after Roux-en-Y choledochojejunostomy or hepaticojejunostomy has not been described in the English-language literature. This report details the diagnostic and operative management of the first patient with sump syndrome after hepaticojejunostomy. The presumed pathophysiology was reflux of vegetable matter up the efferent limb, resulting in hepatic duct obstruction and cholangitis. The patient ultimately required complex choledochoscopic drainage of the intrahepatic biliary tree and revision of the previous Roux-en-Y hepaticojejunostomy.     

Intrahepatic bile duct injury and nodular regenerative hyperplasia of the liver in a patient with polyarteritis nodosa

Although involvement of the hepatic vasculature in patients with polyarteritis nodosa is not unusual, biliary manifestations are very rare. We describe a patient with polyarteritis nodosa presenting with a febrile cholestatic anicteric syndrome. Histological examination of the liver revealed necrotizing arteritis of small hepatic arteries associated with significant lesions of intrahepatic bile ducts of the sclerosing cholangitis type, i.e. fibrous collar around the ducts, periductal inflammation and ductal proliferation. Concomitant nodular regenerative hyperplasia was found, a condition which has rarely been described in association with polyarteritis nodosa. We think that hepatic arteritis compromising arterial blood flow to the liver was responsible for the most likely ischemic nature of the bile duct injury and the nodular regenerative hyperplasia seen in our patient.     

Role of the splanchnic nerve in hypotension induced by acute obstructive suppurative cholangitis

A model of acute suppurative cholangitis with septicemia but without shock was made in 14 rabbits. Fourty-eight hours afterwards, reoperation was performed with the right major splanchnic nerve and right celiac plexus exposed for monitoring. A catheter with an inflatable rubber bag was inserted into the common bile duct via the duodenum for injection with water into the rubber bag to produce a biliary high pressure of 20 kPa, which was subsequently maintained for 2 hours. The right major splanchnic nerve impulse frequency was found significantly increased (P < 0.01). The study shows that the fall of blood pressure or shock in the early stage of acute obstructive suppurative cholangitis is induced predominantly by acute biliary hypertension, and our findings would be complementary to Reynolds' hypothesis of the production of shock.     

K+ Channel density increases selectively in the endfoot of retinal glial cells during development of Rana catesbiana

BACKGROUND: We investigated the bile duct wall thickness measured on intraductal US in patients who had not undergone biliary drainage, with special attention to the influence of cancer at the distal bile duct, bile duct stones, obstructive jaundice, longitudinal cancer extension, and primary sclerosing cholangitis on wall thickness. METHODS: The study included 183 patients. Patients who had undergone previous biliary drainage were excluded. Intraductal US was performed by the transpapillary route with use of a thin-caliber ultrasonic probe (2.0 mm diameter, 20 MHz frequency). The bile duct wall thickness (width of the inside hypoechoic layer) was retrospectively measured on US images. RESULTS: Bile duct wall thicknesses of the common hepatic duct for the control group (n = 95), cancer at the distal bile duct group (n = 9), bile duct stone group (n = 56), and obstructive jaundice group (n = 17) were 0.6 +/- 0.3 mm (mean +/- SD), 0.8 +/- 0.5 mm, 0.8 +/- 0.6 mm, and 0.8 +/- 0. 5 mm, respectively. No significant differences (p > 0.05) were found between them. However, wall thickness for the cancer extension to the common hepatic duct group (n = 4, 2.0 +/- 0.4 mm) and sclerosing cholangitis group (n = 2, 2.5 +/- 0.4 mm) were significantly greater than in the other groups (p < 0.005). CONCLUSIONS: In patients who have not undergone previous biliary drainage, the bile duct wall thickness was not thicker in patients with obstructive jaundice. However, the duct wall was significantly thicker in patients with either longitudinal cancer extension or primary sclerosing cholangitis compared with that of other groups.     

Hemobilia caused by a giant benign hemangioma of the liver: report of a case

We report herein the extremely unusual case of a 39-year-old woman in whom a giant cavernous hemangioma caused hemobilia. Cavernous hemangioma is the most common benign neoplasm of the liver and rarely causes any clinical symptoms or signs, while hemobilia usually occurs secondary to accidental operative or iatrogenic trauma, vascular disease, inflammatory disorders, gallstones, or tumors of the liver. Although invasive or malignant hepatic tumors often result in a communication between the biliary tract and the blood vessels, only one case of hemobilia caused by a benign cavernous hemangioma has ever been reported, but with no details about the patient. Our patient presented to a local hospital with severe melena as the initial main symptom, where ligation of the right hepatic artery was performed. This failed to relieve her symptoms, and she was subsequently referred to our department where a right hepatectomy was performed. Histopathological examination revealed no malignancy combined with the tumor; however, the hemangioma was exposed to the bile duct in segment VIII, which was presumably the cause of the hemobilia. This patient remains in good health almost 6 years after her operation. To the best of our knowledge this is the first case report of hemobilia caused by a cavernous hemangioma, and is accompanied by a detailed analysis.     

Needs, demands and manpower balance. Dentists/populations. FDI Commission, 1996

BACKGROUND:The cause of extrahepatic portal vein obstruction in childhood is unknown. We investigated the anatomical features of extra hepatic portal vein obstruction to clarify its cause. STUDY DESIGN: We studied portal venous anatomy in 10 patients with extrahepatic portal vein obstruction without hepatic disturbances ranging in age from 1 to 7 years (mean age, 4.2 years) using ultrasonography, portal venography, cholangio-computed tomography, and magnetic resonance imaging. RESULTS: The extrahepatic portal vein was not obliterated, but it crossed over the common bile duct from the left to the right side at the cranial level of the pancreas and ran in a cranial direction along the right side of the common bile duct or coiled itself around the bile duct. Thus, the extrahepatic portal vein formed a tortuous eta-shape. CONCLUSIONS: The portal vein was not obstructed in patients with extrahepatic portal vein obstruction but formed a characteristic eta-shape by coiling itself around the common bile duct, suggesting that extrahepatic portal vein obstruction has an embryological cause.     

Choledocholithiasis at the hepatic confluence mimicking a hilar cholangiocarcinoma

Adenocarcinomas of the bifurcation of the hepatic ducts (Klatskin tumors) are a relatively rare cause of obstructive jaundice. Differential diagnosis includes other neoplastic lesions, sclerosing cholangitis, Mirizzi's syndrome and benign strictures. We present a 46 year-old white female with a 2 month history of epigastric pain and progressive jaundice. Endoscopic retrograde cholangiopancreaticography (ERCP) revealed a filiform stenosis of the right hepatic duct and an obstructed left hepatic duct, an image strongly suggestive of a Klatskin tumor. The correct diagnosis was achieved, however, by percutaneous transhepatic cholangiography (PTC), which disclosed a gallstone at the common hepatic duct bifurcation and multiple small concrements in the left hepatic duct. After endoscopic removal of the gallstones in the biliary tree and laparoscopic cholecystectomy, the patient was discharged on the third post-operative day. Protuberant tumors and round biliary stones may be confused at ERCP.     

The orphan receptor CRF2-4 is an essential subunit of the interleukin 10 receptor

BACKGROUND/AIMS: Models of hepatopulmonary syndrome require both hepatic injury and portal hypertension to develop pulmonary microvascular and gas exchange abnormalities. Recently, increased endothelin-1 levels associated with vasodilatation, have been observed in cirrhosis. We investigated endothelin-1 production in common bile duct ligated animals with hepatopulmonary syndrome in comparison to partial portal vein ligated animals that do not develop hepatopulmonary syndrome. METHODS: Organ and plasma endothelin-1 were measured in sham, bile duct ligated and portal vein ligated rats, and Northern analysis and immunohistochemistry were performed in liver. Plasma endothelin-1 levels were correlated with pulmonary endothelial nitric oxide synthase levels and alveolar-arterial oxygen gradients. RESULTS: Hepatic and plasma endothelin-1 increased only after bile duct ligation, and were accompanied by increased hepatic endothelin-1 mRNA and increased endothelin-1 protein in biliary epithelium. Plasma endothelin-1 levels correlated directly with both pulmonary endothelial nitric oxide synthase levels and alveolar-arterial gradients. CONCLUSIONS: Enhanced hepatic production and increased plasma levels of endothelin-1 occur after bile duct ligation, but not after portal vein ligation, and correlate with associated molecular and gas exchange alterations in the lung. Endothelin-1 may contribute to the pathogenesis of hepatopulmonary syndrome.     

A microcholangiographic study of liver disease models in rats

RATIONALE AND OBJECTIVES: Rats develop hepatobiliary injury due to small bowel bacterial overgrowth (SBBO) that, at specimen, resembles cholangiography sclerosing cholangitis. To better visualize the smaller bile ducts, we used microcholangiography to determine the spectrum of biliary lesions in this and five other models of liver disease. METHODS: The models studied were as follows: (1) Surgically created jejunal, self-filling blind loops induce SBBO. (2) Intraperitoneal injection of a bacterial cell wall polymer, peptidoglycan-polysaccharide (PG-PS), causes granulomatous hepatitis. (3) Intraperitoneal injection of endotoxin (lipopolysaccharide) causes sinusoidal congestion and shock. (4) Bile duct ligation induces bile duct proliferation. (5) Alpha-naphthyl-isothiocyanate (ANIT) induces bile duct proliferation. (6) Carbon tetrachloride (CCl4) causes fibrosis and cirrhosis. Warmed barium sulfate, gelatin, and saline were injected in the extrahepatic bile duct. Liver slices (2 mm) underwent microradiographic techniques, and images were correlated with histology. RESULTS: Rats with SBBO had irregular and dilated extrahepatic bile ducts with thickened walls. Rats treated with endotoxin and CCl4 had normal microcholangiograms. Bile duct proliferation was identified following ANIT and bile duct ligation. Rats given PG-PS demonstrated irregular intrahepatic bile ducts. Microcholangiograms following SBBO and PG-PS showed similarities including focal ductal dilatation, narrowing, proliferation, and destruction. CONCLUSION: Various models of liver injury induce characteristic cholangiographic appearances. Microcholangiography is useful in examining biliary tract lesions and complements histology.     

Yamakawa prosthesis with prolonged placement as a therapy concept exemplified by benign biliary stricture

AIM: As an alternative method to the operative revision of benign bile duct strictures, we report the use of a large-bore bile duct prosthesis (Yamakawa prosthesis) in one patient. METHODS: Bilateral percutaneous transhepatic implantation of Yamakawa prostheses (14 F right side, 12 F left side) was performed without adjunctive balloon dilatation. The prostheses were exchanged every 8 weeks under continuous antibiotic treatment and were finally removed after 8 months. RESULTS: Control cholangiography showed a normal intrahepatic biliary system on the right side and a 50% stenosis at the orifice of the left hepatic duct. Follow-up over 18 months showed no signs of recurrent disease. CONCLUSIONS: In comparison to balloon dilatation and implantation of metallic stents, prolonged bilateral splinting with large-bore Yamakawa prostheses seems to be an alternative for the treatment of benign bile duct strictures.     

15 years of endoscopic therapy in choledocholithiasis

INTRODUCTION: The relevance of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of common bile duct stones has increased since the introduction of laparoscopic cholecystectomy in 1989-1990. METHODS: The number, indications, success and complication rate of ERCP were analyzed retrospectively in 1121 consecutive patients with bile duct stones treated at Berne University Hospital between 1980 and 1994. RESULTS: The number of patients undergoing endoscopic stone extraction increased slowly from 1980 to 1990, but has shown a 4-fold increase in the last 5 years parallel to the introduction of laparoscopic cholecystectomy. Failure to diagnose and remove bile duct stones decreased 5-fold from 23% (14 of 60 patients) in 1986 to 4.4% (10 of 225 patients) in 1994. Major complications occurred in 3.2% (30 of 617 patients) and consisted of acute pancreatitis (1.6%), hemorrhage of the papilla (1%), and cholangitis (0.6%). The severity but not the number of complications has decreased in the last 15 years. CONCLUSION: Gallbladder stones with common bile duct stones are usually treated by endoscopic stone extraction combined with laparoscopic cholecystectomy. Open operation with bile duct exploration is reserved for a small subgroup of patients with specific problems.     

Segmental pericholangial fibrosis: a peculiar benign fibrosing disease at the hepatic hilum

The authors report on a 9-year-old child who underwent surgery to remove a tumor of the hepatic hilum with preoperative radiographic studies suggestive of malignancy, but whose surgical specimens showed a peculiar fibrosing disease. The lesion was localized to the bifurcation of the hepatic duct, where the bile duct wall and the surrounding tissue was markedly fibrotic. No malignant cells or epithelial destruction were seen. The patient's postoperative course was uneventful, and he is without any sign of recurrence 2 years after surgery. Because the histological features of this case do not correspond to any established disease, including primary sclerosing cholangitis, the authors believe it represents a new entity, segmental pericholangial fibrosis. Local resection resulted in a good outcome. A review of the literature disclosed a few similar cases with a benign clinical course.     

Surgical treatment for iatrogenic damage at the confluence of hepatic duct

Since 1989, 4 patients with iatrogenic bile duct injuries at the level of bifurcation were treated. Among them, the bifurcation together with both right and left hepatic duct had had wrongly been resected in 2 cases. The bifurcation was partially resected in the other 2 cases. The establishment of a permanent hepaticoentertostomy is essential. Abnormal bile flow would impede surgical effect, hence in the author's opinion, peripheral hepaticoenterostomy such as Longmire's procedure is unsuitable for iatrogenic bile duct injuries. The author's special technique for adequate exposure and accurate dissection of intrahepatic bile ducts is described. Four cases have been followed up for 7 months to 5 years with good result.     

Mass screening of colorectal cancer: where are we up to?

BACKGROUND AND STUDY AIMS: Conventionally, acute cholangitis is managed by placing a nasobiliary drainage catheter. We have attempted to place a biliary endoprosthesis in such patients as an alternative to using nasobiliary catheter drainage. PATIENTS AND METHODS: Twenty-seven patients with acute cholangitis were managed by placement of 7-Fr straight biliary endoprostheses instead of using nasobiliary drainage catheters to decompress the biliary system. The procedure was carried out without sphincterotomy and without image intensification. RESULTS: Biliary endoprosthesis placement was successfully carried out in all the patients. Definitive treatment was then provided to all but four patients, who either had inoperable cancer or were at high risk for surgery. Early stent occlusion occurred in one patient, and in another patient the Dormia basket became entrapped while stones were being removed from the common bile duct. There were no mortalities. CONCLUSIONS: Biliary endoprosthesis placement is safe, easy to perform, and is a cheaper alternative to endoscopic nasobiliary drainage.     

Mucinous biliary obstruction associated with a cystic adenocarcinoma of the pancreas

Obstruction of the biliary tree by large amounts of mucinous material is reported in a patient with a mucin-producing cystic adenocarcinoma of the pancreas invading the common bile duct. Although preoperative endoscopic retrograde cholangiography suggested bile duct invasion, mucinous obstruction, as in the previous cases in which it has been reported, was not suspected. Mucinous obstruction, although unusual, should be considered in patients with cystic carcinomas of the pancreas in the presence of jaundice or episodes of cholangitis.     

The equivalence of SF-36 summary health scores estimated using standard and country-specific algorithms in 10 countries: results from the IQOLA Project. International Quality of Life Assessment

Open choledochostomy still represents an important step of biliary surgery, even during the era of laparoscopic surgery. Although its application has decreased with the widespread use of endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, still there are some patients in whom it is necessary to perform open choledochostomy and place a T-tube. The morbidity and mortality rates depend mainly on the presence or absence of an acute suppurative cholangitis, rather than the performance of the choledochostomy. In patients with mild cholangitis or those no cholangitis and less than 60 years of age, the mortality rate is lower than that observed after ERCP. This procedure is still an important technique for surgeons dedicated to biliary surgery, and therefore several technical aspects of common bile duct exploration are important to remember.     

Bile leakage resulting from clip displacement of the cystic duct stump: a potential pitfall of laparoscopic cholecystectomy

We present the case of a patient who underwent successful endoscopic nasobiliary drainage (ENBD) for bile leakage resulting from clip displacement of the cystic duct stump sustained during a laparoscopic cholecystectomy (LC). This 69-year-old man was admitted with symptomatic cholecystolithiasis. After LC was performed, intraoperative cholangiography (IOC) revealed no abnormal findings. However, postoperatively, bilious material began to appear from the intraabdominal drain. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed bile leakage from the end of the cystic duct stump. ENBD was performed. Cholangiography using the ENBD tube 14 days later failed to show a bile leak. The ENBD was subsequently removed. The patient improved rapidly with no complaints. Bile leakage due to clip displacement from the cystic duct stump is a potential pitfall of LC, especially if IOC is normal. We recommend careful cystic duct ligation, combined with the use of superior quality ligation clips, to prevent this complication. ENBD is a useful technique to prevent bile leakage after this complication.     

Increased neutrophil function induced by bile duct ligation in a rat model

Neutrophil function was studied in rats with common bile duct ligation. Superoxide production stimulated by phorbol myristate acetate, opsonized zymosan or formyl-methionyl-leucyl-phenylalanine; phagocytosis; and chemotaxis were significantly greater in neutrophils from rats with common bile duct ligation than in sham-operated control rats. Enhanced neutrophil activity was observed within 12 hr of bile duct ligation; it remained increased during the 15-day study. Preincubation of neutrophils from control rats with sera of rats with common bile duct ligation did not increase superoxide generation. This suggests that the high superoxide production observed in neutrophils of rats with common bile duct ligation was not an immediate effect of the serum. Neutrophils of rats with portal vein ligation exhibited normal activity, indicating that portal systemic shunting per se is not the underlying mechanism for increased activity. The elevated levels of AST and alkaline phosphatase, indicating liver damage, that appeared within 12 hr of bile duct ligation correlated with the increased superoxide generation.