Ampullary Dysfunction Research Articles

Radiologic findings of biliary complications post liver transplantation.

Liver transplantation is a potentially curative treatment for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy. Despite tremendous advancements in surgical techniques and immunosuppressive management, there remains a high rate of post-transplant complications, with one of the main complications being biliary complications. In addition to anastomotic leak and stricture, numerous additional biliary complications are encountered, including ischemic cholangiopathy due to the sole arterial supply of the bile ducts, recurrence of primary biliary disease, infections, biliary obstruction from stones, cast, or hemobilia, and less commonly cystic duct remnant mucocele, vanishing duct syndrome, duct discrepancy and kinking, post-transplant lymphoproliferative disorder, retained stent, and ampullary dysfunction. This article presents an overview of biliary anatomy and surgical techniques in liver transplantation, followed by a detailed review of post-transplant biliary complications with their corresponding imaging findings on multiple modalities with emphasis on magnetic resonance imaging and MR cholangiopancreatography.

Where Is the Optimal Site for Division of Donor and Recipient Bile Duct for Duct-to-duct Anastomosis During Liver Transplantation?

Background: The blood supply of the bile duct (BD) is a key to minimizing biliary complications (BC) after liver transplantation (LT). Method: A literature review was performed. Results: The retroportal artery (RPA) and 3 and 9 o'clock arteries were first reported by Northover and Terblanche in 1979. They found the RPA in all 21 human resin casts and classified it into two variants; type I RPA arising from the superior mesenteric artery or the Coeliac trunk, and crossing the back of the portal vein to join the posterior superior pancreaticoduodenal artery: and type II RPA which crosses the posterior surface of the supraduodenal BD, and ascends to join the right hepatic artery. They recommended making the donor BD as short as possible. Rath et al described 6 types of marginal arteries of the BD. They suggested dividing both donor and recipient BD just below the confluence of the cystic duct. According to anatomical descriptions of the RPA, which should be included in any description of connective tissue related to the pancreatic head, and contains the BD innervation from the coeliac and superior mesenteric nerve plexuses. Higher division is preferable in order to avoid injury to the recipient RPA and accompanying nerves, which may cause ampullary dysfunction on the recipient. Conclusion: The focus has always been on the donor, but we identify preservation of arterial inflow and innervation of the recipient BD as being important. Deeper consideration and modification of techniques for these small structures may reduce BC after LT.

Peripheral and central vestibular system findings in Meniere's disease.

Meniere's Disease (MD) is a chronic disease that is characterized by intermittent episodes of tinnitus, vertigo, and progressivefluctuating sensorineural hearing loss together with aural fullness. The aim of this study is to evaluate Meniere's disease patients with vestibular test battery as Videonystagmography (VNG), Vestibular Evoked Myogenic Potentials (VEMPs) and Video Head Impulse Test (V-HIT) to assess peripheral and central vestibular systems. 16 bilateral, 17 unilateral patients suffering from MD (mean age, 40.90 years, range, 23 to 66 years; 20 women and 13 men) comprised the study group, and 39 healthy (mean age, 38.10 years, range from 21 to 60 years; 22 women and 17 men) volunteers formed control group. Evaluation of peripheral and central vestibular systems changes with oculomotor tests, caloric test, C-VEMPs, O-VEMPs, and the evaluation of the vestibular ocular reflex (VOR) using the V-HIT. Twenty-six ears out of the forty-nine ears that were affected by Meniere's disease were diagnosed as otolith or ampullary dysfunction. As to O-VEMPs testing, N1 and P1 waves could not be obtained from thirty of the forty-nine ears affected by Meniere's disease. As for obtained N1 and P1 waves, prolonged N1 and P1 wave latencies, and reduced amplitude was observed in Meniere's group. P1 and N1 waves were not observed in 5 bilateral and 2 unilateral Meniere's patients (12 ears out of 49 affected ears) in C-VEMPs recordings (23.9%). In Meniere's patients' group, 44.9% of the velocity gain values were obtained in the pathologic borders of v- HIT. In addition to lower velocity gain, higher ratios of asymmetry were obtained from the ears affected with Meniere's disease. According to these results, it can be concluded that Meniere's disease significantly affects the peripheral vestibular system but the functions of the central vestibular system were not affected.

Biliary complications after liver transplantation: Assessment with MR cholangiopancreatography and MR imaging at 3T device

PurposeOur study was aimed to assess the diagnostic value of MR cholangiopancreatography (MRCP) and MR imaging at 3 T device when evaluating biliary adverse events after liver transplantation. Materials and methodsA series of 384 MR examinations in 232 liver transplant subjects with suspected biliary complications (impaired liver function tests and/or biliary abnormalities on ultrasound) were performed at 3 T device (GE-DISCOVERY MR750; GE Healthcare). After the acquisition of axial 3D dual-echo T1-weighted images and T2-weighted sequences (propeller and SS-FSE), MRCP was performed through coronal thin-slab 3D-FRFSE and coronal oblique thick-slab SSFSE T2w sequences. DW-MRI of the liver was performed using an axial spin-echo echo-planar sequence with multiple b values (150, 500, 1000, 1500 s/mm2) in all diffusion directions. Contrast-enhanced MRCP was performed in 25/232 patients. All MR images were blindly evaluated by two experienced abdominal radiologists in consensus to determine the presence of biliary complications, whose final diagnosis was based on direct cholangiography, surgery and integrating clinical follow-up with ultrasound and/or MRI findings. ResultsIn 113 patients no biliary abnormality was observed. The remaining 119 subjects were affected by one or more of the following complications: non-anastomotic strictures including typical ischemic-type biliary lesions (n = 67), anastomotic strictures (n = 34), ampullary dysfunction (n = 4), anastomotic leakage (n = 4), stones, sludge and casts (n = 65), vanishing bile duct (n = 1). The sensitivity, specificity, PPV, NPV and diagnostic accuracy of the reviewers for the detection of all types of biliary complications were 99%, 96%, 95%, 99% and 97%, respectively. ConclusionMR cholangiopancreatography and MR imaging at 3 T device are extremely reliable for detecting biliary complications after liver transplantation.

Bile Duct Anastomosis Supplied With Biodegradable Stent in Liver Transplantation: The Initial Experience

BackgroundThe most common biliary complications after orthotopic liver transplantation are bile leaks, anastomotic and intrahepatic strictures, stones, and ampullary dysfunction. These complications can occur in up to 10% to 30% of liver transplant recipients. Leaks occur early in the posttransplant period; the stricture formation typically graduates over time. MethodsTen patients underwent transplantation in our preliminary study: 5 were randomized to the group with stent placement and 5 to the control group. We investigated the role of an absorbable biliary stent with the goal of proving patency of duct-to-duct biliary anastomosis. The stents are made of machine-knitted polydioxanone monofilaments. ResultsOur initial results show that duct-to-duct biliary reconstruction using an absorbable internal stent had good patency in all 5 patients. There were no signs of biliary leakage accompanying the anastomoses in any of the cases, and there was no stone formation observed after liver transplantation. The biliary stent was completely absorbed, with no adverse effects. ConclusionsBased on our initial experience and data, we concluded that biodegradable stents can be successfully and safely used in clinical practice. Further large prospective randomized studies are needed to estimate the efficacy of the bioabsorbable stents.

Comment on "Usher's Syndrome: Evaluation of the Vestibular System with Cervical and Ocular Vestibular Evoked Myogenic Potentials and the Video Head Impulse Test".

OBJECTIVE The Usher's syndrome (USH) is composed of a group of inherited disorders characterized by a dual sensory impairment of the audiovestibular and visual systems. Despite the established hearing loss, few authors have investigated vestibular dysfunction in these patients.The aim of this article is to investigate otolith or ampullary dysfunction in a group of patients affected by USH by means of a diagnostic protocol using caloric vestibular tests, cervical vestibular evoked myogenic potentials (C-VEMPs), ocular vestibular evoked myogenic potentials (O-VEMPs), and video head impulse test (v-HIT) to show any selective damage of the vestibular nerve and also to identify if it is present in patients with a previous diagnosis of USH Type II. STUDY DESIGN Prospective study with C-VEMPs, O-VEMPs, and v-HIT. SETTING Tertiary referral center. PATIENTS Fifteen patients with USH. INTERVENTION Evaluation of otolith dysfunction with caloric test, C-VEMPs, and O-VEMPs and the measurement of the vestibular-ocular reflex using the v-HIT. RESULTS Only three cases showed normal values of all the vestibular tests performed. O-VEMPs and C-VEMPs appeared pathologic in nine and seven cases, respectively. V-HITs showed ampullary dysfunction in 10 patients. In our study, eight of the 11 patients belonging to the group of USH Type II showed a pathologic response to at least one of the vestibular tests performed. CONCLUSION Today, in patients affected by USH, any vestibular diagnostic protocol must include VEMPs and v-HIT to confirm the vestibular damage, identify selective deficit of the vestibular nerve, and provide useful information for a correct classification of USH.

Usher's Syndrome: Evaluation of the Vestibular System with Cervical and Ocular Vestibular Evoked Myogenic Potentials and the Video Head Impulse Test.

The Usher's syndrome (USH) is composed of a group of inherited disorders characterized by a dual sensory impairment of the audiovestibular and visual systems. Despite the established hearing loss, few authors have investigated vestibular dysfunction in these patients.The aim of this article is to investigate otolith or ampullary dysfunction in a group of patients affected by USH by means of a diagnostic protocol using caloric vestibular tests, cervical vestibular evoked myogenic potentials (C-VEMPs), ocular vestibular evoked myogenic potentials (O-VEMPs), and video head impulse test (v-HIT) to show any selective damage of the vestibular nerve and also to identify if it is present in patients with a previous diagnosis of USH Type II. Prospective study with C-VEMPs, O-VEMPs, and v-HIT. Tertiary referral center. Fifteen patients with USH. Evaluation of otolith dysfunction with caloric test, C-VEMPs, and O-VEMPs and the measurement of the vestibular-ocular reflex using the v-HIT. Only three cases showed normal values of all the vestibular tests performed. O-VEMPs and C-VEMPs appeared pathologic in nine and seven cases, respectively. V-HITs showed ampullary dysfunction in 10 patients. In our study, eight of the 11 patients belonging to the group of USH Type II showed a pathologic response to at least one of the vestibular tests performed. Today, in patients affected by USH, any vestibular diagnostic protocol must include VEMPs and v-HIT to confirm the vestibular damage, identify selective deficit of the vestibular nerve, and provide useful information for a correct classification of USH.

Biliary complications after orthotopic liver transplantation: MRCP findings

Orthotopic liver transplantation is a widely accepted treatment for end-stage liver disease and selected cases of hepatocellular carcinoma. Despite surgical progresses, biliary complications after transplantation remain a serious cause of morbidity, mortality, and graft dysfunction or failure in recipients. Early complications occur within a few weeks after transplantation and are mainly represented by bile leakage. Late complications, which become evident from 3 months to years, include strictures, stones, intraductal debris or sludge formation, kinking and ampullary dysfunction. Donor-to-recipient common bile duct disproportion has been reported as a borderline condition. Diagnosis is challenging because of the low specificity of clinical and biologic findings. Sonography does not provide projectional images of the biliary tract or direct evaluation of the anastomoses. Moreover, direct cholangiographic procedures have an unacceptable rate of complications to be used in patients with low clinical suspicion. Magnetic resonance cholangiography is a safe and accurate tool, playing an increasing role in the diagnosis and management of biliary complications. Heavily T2-weighted images provide panoramic, detailed evaluation of the biliary tract, showing biliary complications as a variable combination of bile duct dilatation, strictures, filling defects, fluid collections and peculiar morphologic changes, as described in this paper.

Pancreatobiliary Complications After Composite Visceral Transplantation: Incidence, Diagnosis and Management

Background: Combined liver-intestinal (L/SB) and multivisceral (MV) transplantation has been increasingly utilized with significant improvement in outcome. This is the first report to address the potential risk and management of pancreatobiliary (PB) complications in this unique population. Aim: Assess incidence, clinical features and management outcome of PB complications after the different types of the composite visceral graft. Methods: Between May 1990 and October 2006, a total of 227 consecutive patients received a composite visceral graft. Of these, 115 (51%) were adults and 112 (49%) were children. The composite visceral grafts were L/SB in 130 (57%) and MV in the remaining 97 (43%). The pancreas was included in 61 (53%) of the L/SB and the liver was excluded in 25 (26%) of the MV. Most donors were ABO identical and HLA matching was random with positive cross match in 23%. Immunosuppression was tacrolimus based and induction was used in 150 patients (66%). With a mean cold ischemia time of 9 ± 2 hours, UW solution was used to preserve the allograft in 82% and HTK in 18%. With ERCP being the gold standard for the diagnosis of biliary complications and pancreatic leak, significant injury of the pancreatic gland was diagnosed according to serum tests and operative findings. Results: A total of 28 PB complications were diagnosed in 20 patients with an overall incidence of 9%. Risk was similar among L/SB and MV recipients with a rate of 8% and 10%, respectively. Of the 28 morbid events, 9 were biliary complications alone, 11 were isolated pancreatic injury and 8 were combined pathology. Biliary complications included bile leak (n = 5), bile cast syndrome (n = 4), ampullary dysfunction (n = 3) and recurrent ascending cholangitis (n = 1). Pancreatic injury was necrotizing pancreatitis in 7, distal duct fistulae in 6 and chronic calcific pancreatitis in 2. ERCP was instrumental in diagnosis and treatment of cases with ampullary dysfunction, bile cast syndrome and non-surgical PB leak. However, surgical intervention was performed in patients with significant pancreatic allograft necrosis and anastomotic biliary leak. With no direct complication related mortality, all morbid events were successfully treated with the exception of a case with persistent pancreatico-cutaneous fistula. With no statistically identifiable risk factors, there was a trend toward more pancreatitis events with HTK use. Conclusions: PB complications are not uncommon after composite visceral transplantation. Early diagnosis and prompt intervention with combined surgical and endoscopic approach is essential for proper management and successful outcome.

Biliary Complications After Liver Transplantation.

The incidence of biliary complications after liver transplant is estimated to be 8% to 20%. Post-liver transplant biliary complications may lead to acute and chronic liver injury. The early recognition and prompt treatment of such complications improves the long-term survival of the patient and graft. An understanding of the type of biliary reconstruction, the rationale for creating a particular anastomosis, and the technical difficulties in reconstructing the biliary tract are important in assessing and managing complications after liver transplant. Because the clinical presentation of these patients may be subtle, the physician must be aggressive and thoughtful in ordering and interpreting the diagnostic tests. Important points to remember are 1) that noninvasive examinations may fail to detect small obstructions or leaks, 2) a liver biopsy often is performed prior to cholangiography to exclude rejection and ischemia, and 3) the liver biopsy can miss an extrahepatic obstruction by misinterpreting portal inflammation as rejection. Biliary leaks and strictures are the most common biliary complications following liver transplant. Less common complications include ampullary dysfunction and stone/sludge formation. The effective management of biliary complications following a liver transplant depends on understanding the natural history, the prognosis, and the available therapeutic options for each type of complication.

Hereditary polycystic kidney disease (adult form): A microdissection study of two cases at an early stage of the disease

Kidney fragments from two cases of hereditary polycystic kidney disease (adult form) at an early stage were examined by microdissection. Localized cystic cystic dilatations were found in proximal and distal tubules, loops of Henle, and collecting tubules. Entirely normal nephrons and collecting tubules were also observed. Abnormal branching of collecting tubules or the abnormal attachment of nephrons, as described in other microdissection studies, were not found. Our observations do not confirm the hypothesis that the adult form of hereditary polycystic kidney disease is the consequence of ampullary dysfunction during early development.