False-positive whole-body iodine-131 scan due to intrahepatic duct dilatation

Focal retention of radioactivity in the liver on whole-body 131I scan was interpreted as a metastatic lesion in a patient with well-differentiated thyroid cancer. Intrahepatic duct dilatation, usually resulting from biliary tract obstruction by bile stone, is a common disorder and may cause bile stasis. A patient with papillary thyroid cancer and a previous history of biliary tract stones had focal retention of radioactivity in the liver on whole-body 131I scan. Abdominal CT, endoscopic retrograde cholagiopancreatography, radionuclide cholangiography and sequential 131I scans demonstrated that this focal retention of radioactivity was caused by intrahepatic duct dilatation. Focal retention of radioactivity is visualized on delayed images but not on early images. The radioactivity initially increases and then decreases on following days.     

Cholangiopancreatography with magnetic resonance. Clinical use of a new "inversion-recovery" sequence

This study was aimed at correlating the yield of a three-dimensional (3D) inversion-recovery (IR) turbo spin-echo MR cholangiopancreatography (MRCP) sequence with that of ERCP and PTC in the imaging of the normal and abnormal biliopancreatic tract. Thirty patients with suspected biliary and pancreatic diseases were examined with MRCP first and then with ERCP or PTC; they were also submitted to US, CT and conventional MR studies and in 5 of them CT cholangiography was also performed. Five patients were normal and 25 had various obstructive abnormalities: 5 patients had gallbladder stones, 8 common bile duct stones, 5 a cholangiocarcinoma and 7 an adenocarcinoma of the pancreatic head or papilla. MRCP was performed with a superconductive magnet at 0.5 T, with volumetric images on coronal planes acquired using an IR turbo SE sequence (TR 2500, TE 1000, TF 89, 4 NEX) with respiratory triggering and vascular presaturation. Segmental intrahepatic bile ducts were correctly depicted in all the patients with benign or malignant obstruction of the common bile duct, but with some respiratory artifacts. Common bile duct stones were correctly depicted in 7 of 8 patients, but studying also the single coronal slices. With this method, the stones were clearly demonstrated in 22 examined gallbladders. Neoplastic obstruction and the obstruction level were correctly identified in all patients. Pancreatic ducts were shown in normal patients and in 8 of 13 patients with neoplastic or lithiasic obstruction of the common bile duct mainly on the pancreatic head. ERCP was carried out successfully in 5 patients with common bile duct stones and in 7 patients with neoplastic obstruction; in the other cancer patients, PTC was necessary. To conclude, respiratory-triggered 3D IR turbo spin-echo MRCP is a noninvasive technique to study mostly biliary conditions which yields similar information to ERCP and PTC in a large number of patients. Moreover, this sequence can be used with midfield MR units to study the obstruction of the biliary and pancreatic ducts not only when invasive techniques fail, but also routinely.     

Invasive angiology in acute arterial pathology in a critically ill newborn infant

Four patients who complained of symptoms and signs compatible with biliary tract disease and in whom the diagnosis of gallbladder (three cases) and common bile duct ascariasis (one case) was made sonographically are reported. In two patients with gallbladder ascariasis, cholecystectomy corroborated the presence of the round-worms, and was curative. The third patient was a pregnant woman (32nd gestational week) who took piperazine citrate, and a second sonogram performed 29 days later was completely normal. The fourth patient with common bile duct ascariasis underwent choledochotomy with extraction of one ascaris lumbricoides from the common duct, and a T tube was left in place for 15 days. All patients received antiparasitics and had a favorable outcome. Ultrasonography is an important noninvasive diagnostic procedure in the work-up of these patients, who usually describe a clinical picture suggesting gallstone disease: this is especially true in the presence of pregnancy.     

Persistent obstructive jaundice, cholangitis, and biliary cirrhosis due to common bile duct stenosis in chronic pancreatitis

Long strictures of the intrapancreatic portion of the common bile duct were found in 6 patients with chronic pancreatitis. These strictures were responsible for painless obstructive jaundice, recurrent cholangitis, secondary biliary cirrhosis, and chronic abdominal pain difficult to distinguish from that caused by pancreatitis. Endoscopic retrograde cholangiopancreatography and intraoperative cholangiography were invaluable in making the diagnosis and in planning surgical correction. Decompression of the biliary tree by anastomosis of the gallbladder or common duct to the small intestine completely relieved symptoms and allowed liver function to improve significantly. Common duct stricture as a complication of chronic pancreatitis should be considered in the differential diagnosis of extrahepatic biliary obstruction and whenever surgical treatment of chronic pancreatitis is contemplated.     

Cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation

The aim of this study was to delineate clinical features and prognosis of cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation, and to determine methods for managing the disease. A retrospective study of seven patients is presented. A further 27 cases from the Japanese literature were reviewed retrospectively with regard to method of treatment and prognosis. In 11 of 18 patients in whom staging was known the tumour was stage V, representing advanced disease. In seven of 34 cases curative operation was performed; only two patients survived for > 3 years. This poor outcome was due largely to delayed diagnosis of cancer of the gallbladder. Prophylactic cholecystectomy is recommended in patients with this anomalous junction without bile duct dilatation or a malignant lesion in the gallbladder, because of the high incidence of cancer of the biliary tract.     

MR cholangiography: technical advances and clinical applications

Magnetic resonance (MR) cholangiography is a fast, accurate, noninvasive alternative to endoscopic retrograde cholangiography (ERC) in the evaluation of biliary tract disease. Technical improvements in imaging sequences (eg, half-Fourier rapid acquisition with relaxation enhancement) and use of phased-array coils allow high-quality imaging comparable to that available with ERC. In choledocholithiasis, common bile duct stones as small as 2 mm can be detected with MR cholangiography and appear as low-signal-intensity foci within the high-signal-intensity bile. MR cholangiography may help establish the diagnosis of malignant obstruction and is useful in the evaluation of patients in whom ERC was unsuccessful or incomplete. The role of MR cholangiography in the evaluation of intrahepatic duct disease continues to evolve. MR cholangiography plays a crucial role in evaluating postsurgical biliary tract alterations and can be used to demonstrate a variety of congenital anomalies of the biliary tract (eg, aberrant ducts, choledochal cysts, pancreas divisum). In addition, intentional or incidental imaging of the gallbladder with MR cholangiography can be used to identify calculi or help determine the presence and extent of neoplastic disease.     

Preoperative diagnosis of laparoscopic cholecystectomy. Is there an indication for routine intravenous cholangiography?

In a retrospective study including 163 patients we investigated the necessity of i.v. cholangiography in preoperative routine diagnostic workup prior to laparoscopic cholecystectomy. We evaluated the evidence of i.v. cholangiography concerning the anatomy of the biliary system, the evidence of common bile duct or cystic duct stones and the influence on the further therapeutic procedure. While the common bile duct could be demonstrated in 96.3%, the cystic duct could be visualized in only 54.6%. One out of two patients with a short cystic duct was identified. Stones in the gallbladder were recognized in 72.4% of cases, while only two out of three patients with common bile duct stones were diagnosed. In nine cases a deep junction of the cystic duct was found, but there was no influence on further operative procedure. Thus we found no improvement after routine use of i.v. cholangiography concerning the evidence of common bile duct stones or avoidance of intraoperative lesions of the common bile duct. The routine use of i.v. cholangiography prior to laparoscopic cholecystectomy is therefore not justified.     

Use of intraoperative laparoscopic sonography in the diagnosis of hepato-pancreatic-duodenal duct diseases

Laparoscopic doppler sonography was conducted in 245 patients. Its application have permitted to diagnose the diseases of gallbladder, pancreas, liver, common bile duct, duodenum, to determine the inflammation form, to substantiate the extent and tactics of surgical intervention and to reduce the complications frequency.     

Effect of octreotide on dynamic excretion of bile in Chinese acromegalic patients assessed by [99mTc]EHIDA hepatobiliary scan

We used [99mTc]EHIDA hepatobiliary scintigraphy to determine whether both hepatic bile secretion and gallbladder contractility are suppressed in acromegalic patients receiving long-term treatment with the somatostatin analogue octreotide. We studied three groups of patients: group 1, untreated patients; group 2, average dose of octreotide 500 +/- 100 micrograms/day for 33 +/- 4 months; and group 3, 1000 +/- 200 micrograms/day for 33 +/- 4 months. Images were taken at specified time intervals during the 120-min period following injection of EHIDA. After a single injection of octreotide, group 1 patients demonstrated delayed visualization of the radioisotope in the liver, gallbladder, and duodenum. At the end of long-term treatment, group 2 patients showed a delay in appearance of maximal radioactivity in the gallbladder. Two weeks following discontinuation of octreotide, this parameter had decreased significantly (P < 0.001). In group 3, visualization of the liver, gallbladder, and duodenum were prolonged, with delayed visualization of the gallbladder persisting two weeks after withdrawal (P < 0.005). These results indicate that gallbladder contractility is decreased after a single injection of octreotide and that during chronic octreotide therapy the rate of bile secretion is reduced. Impaired gallbladder contractility normalizes more rapidly after discontinuation of octreotide in patients receiving low doses of the analog.     

Solute focusing techniques for bioseparations

BACKGROUND: Hepatic lesions in sickle cell disease have been studied essentially in autopsy series. Previous reports on living patients are rare and concern a limited number of cases. The aim of the present study is to report the clinical, biochemical, and hepatic histological findings in 26 living patients with sickle cell disease and hepatobiliary disease. PATIENTS AND METHODS: Twenty-six of 510 patients with sickle cell disease, in whom liver tissue was available for histological analysis, were selected. In 21 patients, biopsy was obtained during laparotomy for cholecystectomy; 5 patients underwent needle biopsy for hepatomegaly and/or liver test abnormalities. RESULTS: Twenty of the 21 cholecystectomized patients, as well as the 5 other patients, had liver vascular lesions consisting of sinusoidal dilatation (23 cases), perisinusoidal fibrosis (19 cases), and acute ischemic necrosis (5 cases). It is of interest that the 21 cholecystectomized patients had clinical signs of complicated cholelithiasis, and that 20 of them had gallbladder stones, with common bile duct lithiasis in only 1 case. In the 25 patients without common bile duct obstruction, symptoms might have been due to vascular lesions, but it must also be noted that in the cholecystectomized patients they did not persist or recur following surgery. In one cirrhotic patient, marked sinusoidal lesions might have favored severe hepatocellular failure that led to liver transplantation. In another patient, fatal hepatocellular insufficiency was possibly due to ischemia. The nonvascular lesions that were observed, ie, chronic persistent or mildly active hepatitis (11 cases) and cirrhosis (2 cases), were always associated with vascular lesions. CONCLUSION: These results suggest that in sickle cell disease: (1) hepatic lesions are mainly vascular; (2) these lesions can be responsible for acute and/or chronic ischemia that may be severe; (3) symptoms suggestive of acute cholecystitis and/or biliary tract obstruction might be, at least in part, explained by vascular lesions; and (4) biliary tract surgery indications should be considered more carefully.     

Reconstruction of the biliary tract using biliary-duodenal interposition of a defunctionalized jejunal limb

Interposition of a defunctionalized limb of jejunum between the confluence of the hepatic ducts and the duodenum seems to have some advantages. Biliary-jejunal anastomosis can be performed in a wider diameter, if necessary; duodenal function is kept almost normal, and the isolated segment of jejunum prevents the duodenojejunal reflux from getting to the biliary tract. The records of 19 patients upon whom hepatico-jejuno-duodenostomy was performed were reviewed. Seventeen patients had iatrogenic lesions and benign strictures of the common bile duct. Two patients had malignant tumors of the common bile duct. The postoperative follow-up period ranged from six months to five years. The average postoperative time was ten days. Two transient bile leaks were observed. Two patients had postoperative episodes of cholangitis. In both, the hepatico-jejunostomy was narrow, and stones were found in the intrahepatic position. A new and wider cholangiojejunostomy was performed. All of the patients were investigated roentgenographically after contrast material was given orally. Only two of the patients were found to have an enteric-biliary reflux which partially filled the intrahepatic biliary branches, but this was only observed at the time the abdomen was compressed.     

Evaluation of MRCP compared to ERCP in the diagnosis of biliary and pancreatic duct

Recently, Magnetic Resonance Cholangiopancreatography (MRCP) is developed as a noninvasive diagnostic modality in the diagnosis of biliary and pancreatic tract. Using Endoscopic Retrograde Cholangiopancreatography (ERCP) as the gold standard, we evaluated the diagnostic quality of MRCP and direct cholangiography. Fifty-six patients (9 cases of cholangiocarcinoma, 5 of gallbladder carcinoma, 1 of gallbladder carcinoma and anomalous arrangement of pancreaticobiliary ductal system, 4 of cholecystlithiasis, 3 of papillary carcinoma, 1 of adenomyomatosis of the gallbladder, 1 of primary sclerosing cholangitis, 1 of hepatolithiasis and postoperative bile duct stricture, 4 of mucin producing pancreatic tumor, 13 of pancreatic carcinoma, 1 of chronic pancreatitis and pancreas divisum, 9 of chronic pancreatitis, and 1 of chronic pancreatitis and biliary stricture) are studied prospectively with MRCP and direct cholangiography (included ERCP and percutaneous transhepatic cholangiography). The image of MRCP accorded with direct cholangiography in twenty-two of 27 patients with biliary tract disease, and in sixteen of 29 patients with pancreatic disease. The different diagnosis is observed in ten of 56 patients. In cases of not visualized gallbladder, pancreatic cyst without communicated to the pancreatic duct, and pre-stenotic dilatation of biliary and pancreatic duct, the image of MRCP was better than that of ERCP. However, the image of MRCP for the diagnosis of either benign or malignant strictures, mucin producing pancreatic tumor, and a branch of pancreatic duct in patients with pancreatic carcinoma were not suitable for evaluation than that of ERCP. In our study, ERCP is superior to MRCP due to the important information for diagnosis such as mentioned above. Therefore we advocate using ERCP as the first diagnostic tool in the diagnosis of biliary and pancreatic duct.     

Isolated agenesis of the gallbladder. An intraoperative problem

Agenesis of the gallbladder and cystic duct is a rare congenital malformation. In 40-70% of cases this anomaly is associated with other gastrointestinal, skeletal, cardiovascular and genitourinary malformations. Lithiasis of the common bile duct is present in 25-50% of cases. In the majority of cases patients are asymptomatic or have symptoms compatible with a biliary disorder. A preoperative diagnosis is extremely difficult and the absence of the gallbladder is often an intraoperative finding. The authors report a case of isolated agenesis of the gallbladder. The relative embryology, development, diagnostic pitfalls, intraoperative behaviour and therapeutic strategies are discussed.     

Current problems with intrahepatic bile duct stones in Japan--congenital biliary malformations as a cause

BACKGROUND/AIMS: In patients with primary intrahepatic bile duct stones, strictures of the biliary duct are often present, but the relationship between these strictures and the formation of the stones remains controversial. Intrahepatic bile duct carcinoma in association with intrahepatic bile duct stones has recently been reported. The present study attempted to ascertain whether bile stasis induced by congenital biliary strictures is the basis for the formation of stones and occurrence of carcinoma. MATERIALS AND METHODS: We analyzed the location of strictures in 58 patients with strictures in the upper portion of the biliary tract including 38 patients with intrahepatic bile duct stones and 9 with intrahepatic bile duct carcinoma. The cell cycle of epithelial cells from the intrahepatic bile duct were analyzed with using proliferating cell nuclear antigen, which is a immunohistochemical staining method. RESULTS: Fifty six of 58 patients had congenital cystic dilatation of the common bile duct (two infant type and 54 adult type). Thirty eight patients had intrahepatic bile duct stones proximal to the strictures at the hepatic hilum. The location of the strictures were classified into four types. Nine patients had intrahepatic bile duct carcinoma and eight of the 9 carcinomas coexisted with intrahepatic bile duct stones. In the nine patients with intrahepatic bile duct carcinoma, the expression of proliferating cellular nuclear antigen (PCNA) in the carcinoma and the normal bile duct epithelium adjacent to the carcinoma was higher than that of patients with hepatocellular carcinoma without anomaly of the biliary duct. CONCLUSION: Considering the location of the strictures and clinical features, the strictures may have been formed congenitally. Furthermore, adult type cysts of the common bile duct with strictures in the upper portion of the biliary tract are thought to be the basis for the formation of primary intrahepatic bile duct stones. The most appropriate treatment for intrahepatic bile duct stones is thus suggested to be removal of the affected hepatic segment including the region of strictures, combined eventually with hepaticoenterostomy.     

Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography

PURPOSE: To compare unenhanced helical computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of common bile duct calculi. MATERIALS AND METHODS: Within 13 months, 51 patients (aged 18-94 years) with clinically suspected choledocholithiasis underwent unenhanced helical CT immediately before undergoing ERCP. CT scans were evaluated for the presence of bile duct stones, ampullary stones, the gallbladder and gallbladder stones, intrahepatic biliary dilatation, and the size of the bile duct at the porta hepatis and in the pancreatic head. ERCP images were evaluated for the presence of bile duct or ampullary stones, as well as for biliary dilatation. RESULTS: Unenhanced helical CT depicted common bile duct stones in 15 of 17 patients found to have stones at ERCP. Three patients had stones impacted at the ampulla, all of which were detected with CT. In addition, there was one false-positive finding at CT. CT had a sensitivity of 88%, a specificity of 97%, and an accuracy of 94% in the diagnosis of common bile duct stones. CONCLUSION: Unenhanced helical CT is useful for evaluating suspected choledocholithiasis.     

Results of treatment of cholelithiasis and its consequences; the so called "postcholecystectomy-syndrome" (author's transl)

Our analysis of 378 patients made after operations for diseases of the gallbladder and bile tract underlines the demand of an exact preoperative diagnostic examination of other abdominal organs, e.g. the oesophagus, stomach, duodenum, liver and pancreas. The value of using modern intraoperative diagnostic procedures for the biliary tract is confirmed. Our analysis also demonstrates the necessity of traeting cholelithiasis surgically at an early stage. Complications of cholelithiasis include a higher risk, a worse prognosis with regard to permanent healing and a higher rate of postoperative lethality.     

Chemical mediation of egg dumping in the lace bug Gargaphia solani Heidemann (Heteroptera: Tingidae)

OBJECTIVE: The purpose of this study was to investigate the use of breath-hold single-shot fast spin-echo MR cholangiopancreatography in neoplastic pancreaticobiliary duct obstruction. MATERIALS AND METHODS: Breath-hold MR cholangiopancreatography was performed for preoperative examination of 32 consecutive patients with pathologically confirmed neoplastic obstruction of the biliary tract or pancreatic duct using a single-shot fast spin-echo sequence. Two observers, unaware of clinical or pathologic findings, independently reviewed the MR cholangiopancreatograms to assess level of obstruction and site of underlying tumor. Pathologic diagnoses, based on surgical or CT-guided biopsy specimens, were pancreatic tumor (n = 12), gallbladder cancer (n = 9), intrahepatic cancer (n = 9), and ampullary cancer (n = 2). RESULTS: On the basis of conventional cholangiography, CT, and surgical findings, 20 patients had isolated bile duct obstruction, 11 patients had combined pancreatic and bile duct obstruction, and one patient had isolated pancreatic duct obstruction. Isolated bile duct obstruction was classified as lobar (n = 5), hilar (n = 12), or distal (n = 3). These levels of obstruction were correctly identified in 27 (84%) and 28 (88%) of the 32 cases by the two observers. The site of the underlying tumor was identified in 27 (84%) and 29 (91%) cases by the two observers. Good interobserver agreement was reached for both level of obstruction (kappa = .70) and identification of tumor site (kappa = .75). CONCLUSION: Breath-hold single-shot fast spin-echo MR cholangiopancreatography is accurate in identifying the level of obstruction and the site of underlying tumor in neoplastic pancreaticobiliary duct obstruction, with good interobserver agreement.     

The importance of clinical symptoms and signs in the diagnosis of community-acquired pneumonia

PURPOSE: 118 Patients with suspected obstruction of the biliary tract of pancreatic duct were examined to evaluate the accuracy of MR cholangiopancreatography (MRCP) in comparison with diagnostic findings in endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Using a 0.5-Tesla MR imaging system (FLEXART, Toshiba) and a QD body-coil, a recently developed heavily T2-weighted fast acquisition spin echo sequence (FASE) was applied. In this FASE sequence two significant features are implemented. A fast spin-echo (SE) sequence allows a large number of echos and conjugate K-space filling speeds up data acquisition. Thus, the acquisition time of single-shot breath-hold images takes only 3 seconds, which makes MRCP a feasible technique even in elderly or suffering patients. There is no need for time-consuming postprocessing procedures. RESULTS: In all MRCP examinations images of satisfactory quality were obtained. In cases of obstruction of the biliary or pancreatic duct, locations and lengths of stenoses were correctly demonstrated. Gallstones within the gallbladder or in the extrahepatic bile ducts were also properly visualised in MRCP. Stenoses caused by non-depicted pancreatic carcinoma, gallbladder carcinoma, or segmental pancreatitis were reliably shown. CONCLUSION: Even if MRCP will not replace ERCP, a number of clinical applications for non-invasive MRCP examination arise: primary diagnosis in patients with obstructive jaundice, obstruction of the biliary or pancreatic duct, if ERCP is not possible due to anatomic reason and in patients scheduled for laparoscopic cholecystectomy.     

Mn-DPDP enhanced MRI in experimental bile duct obstruction

To assess both the effect of Mn-DPDP as a hepatobiliary-specific contrast agent in bile duct obstruction and the relative role of liver and kidney in the elimination of this agent from the body, an animal experiment was set up. Twelve rats were used and divided into three groups. In group 1 the common bile duct was ligated, in group 2 bile duct ligation was limited to one lobe, and group 3 served as control. Magnetic resonance T1-weighted SE images were obtained before and after the injection of 25 mumol/kg of Mn-DPDP during the first 2 h and at day 1, 2, 3, 4, and, in some animals, up to 21 days. In normal rats the absolute enhancement signal-to-noise ratio (S/N) versus time plots obtained from the liver after Mn-DPDP injection returned to precontrast values within 24 h. In the group with common bile duct ligation, important liver enhancement persisted up to 21 days. In the group with selective obstruction, liver intensity normalized after 3 days. The S/N plots from spleen, renal cortex, and obstructed liver lobe showed similarities in time course. The present data indicate that Mn elimination is strongly impaired in the presence of bile duct obstruction. Renal glomerular filtration is ineffective in eliminating Mn from the body. The persisting splenic and renal cortical enhancement suggests that free Mn or some Mn-DPDP metabolite either is strongly bound to plasma proteins and acts as a blood pooling agent and/or is uptaken by the splenic or renal parenchyma.     

In situ nucleic acid hybridization of cytokines in primary biliary cirrhosis: predominance of the Th1 subset

Primary biliary cirrhosis (PBC) is an autoimmune liver disease characterized by destruction of the intrahepatic bile ducts. It is generally believed that cellular immune mechanisms, particularly involving T cells, result in this bile duct damage. The relative strength of Th1 and Th2 responses has recently been proposed to be an important factor in the pathophysiology of various autoimmune diseases. In this study, we have attempted to identify the Th subset balance in PBC, by detection of cytokines specific to the two T-cell subsets, i.e., interferon gamma (IFN-gamma) for Th1 cells and interleukin-4 (IL-4) for Th2 cells. We analyzed IFN-gamma and IL-4 messenger RNA (mRNA) positive cells in liver sections from 18 patients with PBC and 35 disease controls including chronic active hepatitis C, extrahepatic biliary obstruction (EBO), and normal liver, using nonisotopic in situ hybridization and immunohistochemistry. Mononuclear cells expressing IFN-gamma and IL-4 mRNA were aggregated in inflamed portal tracts in PBC livers, but were rarely present in extrahepatic biliary obstruction, alcoholic fibrosis, or normal liver sections. The IFN-gamma and IL-4 mRNA positive cells in PBC livers were detected in significantly higher numbers than in control livers (P < .01). Moreover, IFN-gamma mRNA expression was more commonly detected than IL-4 expression in PBC livers, and the levels of IFN-gamma mRNA expression were highly correlated with the degree of portal inflammatory activity. IFN-gamma mRNA-positive cells were detected primarily around damaged bile ducts that were surrounded by lymphoid aggregates. The data indicate that Th1 cells are the more prominent T-cell subset in the lymphoid infiltrates in PBC.