Bile Aspiration Research Articles

Mo1508 Bile Aspiration Cytology in Diagnosis of Bile Duct Cancer: Factors Associated With Positive Yields

Mo1508 Bile Aspiration Cytology in Diagnosis of Bile Duct Cancer: Factors Associated With Positive Yields

Endoscopically Obtained Bile Aspirate is an Accurate Adjunct in the Diagnosis of Symptomatic Gallbladder Disease

The experience of a single surgeon in a rural hospital over a 10-year period was analyzed with respect to the utilization of endoscopically obtained bile aspirates as an adjunct in the diagnosis of symptomatic gallbladder disease. A retrospective study of the author's entire cholecystectomy experience over a 10-year period with 641 patients was conducted to evaluate the utility of the bile aspirate in the preoperative selection of operative candidates and with respect to the ultimate pathologic diagnostic accuracy of the test. Derivation of preoperative diagnosis via traditional standard means was possible in 479 patients. An endoscopically obtained positive bile aspirate was found in 162 additional patients who failed to have positive traditional diagnostic studies (acalculous gallbladder disease). Micro-pathology was determined to be present in 603 patients (94.07%). In 27 of the 38 negatives, there had been positive radiological studies (71%). In 11 of the 38, a positive preoperative bile aspirate had been obtained (28.9%). Of the 162 patients with a positive bile aspirate, 151 (93.21%) of the gallbladder specimens had confirmatory histologic analysis (92.1% confidence interval ± 3.95%). In patients with symptoms suggestive of clinical gallbladder disease and negative traditional diagnostic studies, the endoscopically obtained bile aspirate has been shown to be a highly reliable tool in establishing the diagnosis and is recommended as an aid in the appropriate selection of candidates who may benefit from cholecystectomy.

Utility of Choledochoscopy/EUS to Diagnose and Treat Choledocholithiasis in Pregnancy

Purpose: The risk of choledocholithiasis is higher during pregnancy due to alteration in bile composition and biliary stasis that occurs during gestation. Treatment of these patients during pregnancy is challenging due to the risks from sedation and fluoroscopy. This is an interesting case of application of new technique to diagnose and treat choledocholithiasis. A twenty-six year old pregnant female at 28 weeks gestation presented with right upper quadrant pain, progressive jaundice, and low-grade fever. Her past medical history was significant for sickle cell disease, preeclampsia and choledocholithiasis. She had undergone a previous ERCP for stone removal after her last pregnancy. Upon presentation to the hospital, her total bilirubin was 6.8, AST 139, ALT 113, ALP 128 and WBC count was 16,500. Transabdominal ultrasound revealed a 9-mm common bile duct with possible filling defect. In order to avoid radiation exposure to fetus by fluoroscopy, EUS and choledochoscopy were used to examined the bile duct and achieve complete clearance. The linear echoendoscope revealed multiple hyperechoic well-rounded stones throughout the common bile duct. A prior sphincterotomy had been performed, so deep cannulation of the bile duct using the SpyGlass choledochoscope (Boston Scientific) was easily achieved. The SpyScope was useful in determining the exact location of the stones. A guidewire was advanced through the SpyScope into the left intrahepatic system. A 10 mm extraction balloon was used to extract multiple yellow pigment stones from CBD. The SpyScope was then reinserted and complete clearance of the CBD was seen. A 10 Fr 5-cm plastic biliary stent was placed to ensure drainage and prevent recurrent cholangitis during the remainder of her pregnancy. The linear echoendoscope was used to confirm adequate placement of the biliary stent. Subsequently, the patient had complete resolution of her symptoms and improvement in her LFT. The incidence of gallstones during pregnancy is estimated to be between 3% and 12%. Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women and may require surgical intervention. In addition to the baseline risks of ERCP, fluoroscopy poses additional risk to the fetus. Various publications have reported using ERCP during pregnancy without fluoroscopy by using bile aspiration for confirmation of CBD cannulation, sphincterotomy and balloon extraction of stones. All these approaches are not perfect with regard to ensuring complete CBD clearance. This case highlights how choledochoscopy and endoscopic ultrasound are safe alternatives to fluoroscopy for evaluation of biliary disorders during pregnancy.

Combining Analysis of Per ERCP Bile Aspiration and Endobiliary Brushing Improve the Diagnostic Yield of Cytology in Malignant Strictures of the Biliary Tract. Mono-Centric Prospective Study

The cytological diagnosis obtained by brushing in malignant biliary strictures is considered to be highly specific but poorly sensitive. Improving diagnostic yield by bile exfoliate cytology has been suggested but is rarely performed. The aim of this prospective study was to assess the diagnostic performance bile aspiration associated with biliary brushing during an ERCP. Patients and Methods: From Jan 2007 to Sept 2008, 82 patients (51 M, 31 F), mean age 70 (32 - 93), among whom ERCP was performed for the treatment of a biliary stricture with suspicion of malignancy, were included. A final diagnosis of cancer was established in 57/82 patients by histology. A surgical resection was contra indicated for highly suspicious of malignant strictures because of the patient terrain or tumoral involvement. After sphincterotomy and crossing of the stricture with a guide wire, a single use brush protected by an 8 Fr catheter (ref. FS-CB-1.5 Cook ®) slipped on the wire was positioned above the stricture. Three to 10 ml of bile were aspirated and collected in a dry sterile tube before and after brushing. Brushing was performed with 10 passages in to-and-fro fashion across the stricture for classical cytological analysis (MGG, Papanicolaou) and in thin layer (Preservcyt ®). After centrifugation of the 2 samples of bile, an analysis was performed on a slide (MGG, Papanicolaou). Results: The biliary strictures were related to 34 pancreatic cancers, 16 cholangiocarcinoma and 7 other cancers including 4 metastatic tumors. Twenty-five were benign. One cholecystitis occurred (1.2%): . For the diagnosis of malignancy, the performance of procedures were as follows: brushing; Se = 65.5%, Sp = 100%, PPV = 100%, NPV = 54.5%, bile samples before brushing: Se = 75.9%, Sp = 100%, PPV = 100%, NPV= 63.2%. Bile samples after brushing did not provide additional diagnostic performance. The cellularity of samples was associated with better sensitivity for the cytological analysis of bile before brushing (p <0001) and brushing (p = 0.02). The best diagnostic performance was obtained by combining cytological analysis of bile before brushing and brushing: Se = 81%, Sp = 100%, PPV = 100%, NPV = 68.6%. The diagnostic sensitivity of combining cytological analysis was significantly higher for cholangiocarcinoma (100%) than for pancreatic cancer (82%) and metastases (66%) (p <0.01). Conclusion: In case of biliary stricture, the aspiration of bile before brushing during an ERCP is a simple and safe procedure. Analysis of bile before brushing in combination with brushing increase significantly the performance of cytological diagnosis of malignant strictures especially for cholangiocarcinoma.

Are the Echogenicities on Intraductal Ultrasonography Really Biliary Microlithiasis?

Intraductal ultrasonography (IDUS) is a useful procedure for diagnosing microlithiasis in the bile duct but it is not easy to differentiate between tiny echogenicity and real microlithiasis. We compared the echogenicity seen on IDUS and the findings of bile microscopy (BM) of bile that was collected in the common bile duct (CBD) to determine whether the echogenicity seen on IDUS is real microlithiasis. This prospective study involved a total of 30 patients who experienced biliary pain (n = 11), acute cholecystitis (n = 11) or indeterminate pancreatitis (n = 8) without a filling defect or obstruction in the bile duct. IDUS was performed during endoscopic retrograde cholangiopancreatography (ERCP), followed by bile aspiration for BM. Endoscopic sphincterotomy (EST) was performed if definite echogenic materials were observed on IDUS. Of the 30 patients, 23 (77%) had echogenic materials visible in the CBD on IDUS. Of these 23 patients, 13 (57%) were found to have biliary crystals by BM. The size of the echogenic materials was the only significant factor associated with BM positivity. Using the receiver operating curve, the optimal size of the echogenicity to differentiate real microlithiasis was 1.4 mm. Optimal concordance between IDUS and BM was observed when the size of the microlithiasis was greater than 1.4 mm; under these conditions the sensitivity and specificity were 71% and 75%, respectively. This information may be useful when deciding whether to perform endoscopic sphincterotomy.

Cost Minimization Analysis Comparing Diagnostic Strategies in Unexplained Pancreatitis

Both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) are commonly performed in the evaluation of idiopathic pancreatitis. However, comparative trials of these modalities are lacking, and thus the ideal endoscopic diagnostic strategy to evaluate idiopathic pancreatitis remains unknown. A decision analysis model of patients with 2 attacks of idiopathic pancreatitis with gallbladder in situ was constructed using TreeAge software. We analyzed cost and overall diagnostic ability of 3 strategies, namely, EUS, ERCP with manometry and bile aspiration, and laparoscopic cholecystectomy. Using the base case analysis, initial EUS was the preferred initial modality for the diagnosis. The expected cost for initial EUS was $4469 compared with $4615 for ERCP and $6268 for laparoscopic cholecystectomy. For cholecystectomy to be the preferred strategy, the total cost would need to be less than $1314, well below any realistic cost estimate. If the prevalence of microlithiasis/sludge was greater than 80%, then cholecystectomy would be preferred, whereas ERCP would be preferred with a prevalence of less than 41%. This cost minimization study identifies EUS as the least costly initial test for the diagnostic evaluation of patients with idiopathic pancreatitis with gallbladder in situ.

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.

Laparoscopic Cholecystectomy for Management of Uncomplicated Gall Bladder Mucocele in Six Dogs

To describe a technique for, and outcome after, laparoscopic cholecystectomy (LC) for management of uncomplicated gall bladder mucocele (GBM) in dogs. Case series. Dogs (n=6) with uncomplicated GBM. Dogs with ultrasonographic evidence of GBM but without imaging or laboratory signs of gall bladder rupture, peritonitis, or extra-hepatic biliary tract rupture that had LC were included. A 4 portal technique was used. A fan retractor was used to retract the gall bladder to allow dissection around the cystic duct with 5 or 10 mm right-angle dissecting forceps. The cystic duct was ligated using extracorporeally tied ligatures supplemented sometimes with hemostatic clips. A harmonic scalpel was used to dissect the gall bladder from its fossa. The gall bladder was placed into a specimen retrieval bag and after bile aspiration the bag was withdrawn through the 11 mm portal incision. Five dogs had mild intermittent clinical signs including vomiting, inappetence, and lethargy. All dogs had successful LC without conversion to an open approach. All dogs with clinical signs had improvement or resolution of signs postoperatively. No important perioperative complications occurred and all dogs were alive at a median of 8 months postoperatively (range, 3-14 months). LC can be accomplished safely and effectively in dogs with uncomplicated GBM. A minimally invasive approach for cholecystectomy can be used for the treatment of GBM in dogs.

An association of gastroschisis and fatal respiratory distress: does prenatal bile aspiration cause early-onset respiratory failure in neonates?

We present a neonate with gastroschisis and evidence of bile aspiration in utero, who developed severe respiratory distress that did not respond to postnatal intensive respiratory care. Although rare, a newborn with gastroschisis may develop severe respiratory distress due to bile aspiration in utero. Given the poor outcome in this case, we suggest a possible role for prenatal diagnosis and therapy.

Microflora of bile aspirates in patients with acute cholecystitis With or without cholelithiasis: a tropical experience

The current study determined the spectrum of biliary microflora with special emphasis on enteric fever organisms in patients with acute cholangitis with and without cholelithiasis or other biliary diseases. The patients were divided into three groups: Group A consisted of patients with acute cholecystitis with cholelithiasis; Group B consisted of patients with acute cholecystitis with gastrointestinal ailments requiring biliary drainage and group C consisted of patients with gallbladder carcinoma. Gallbladder, bile and gallstones were subjected to complete microbiological and histopathological examination. Antimicrobial susceptibility of the isolates was performed as per CLSI guidelines. Bacteria were recovered from 17 samples (32%) in Group A, 17 (51.4%) in Group B and 1 (1.6%) in Group C. The most common organisms isolated were Escherichia coli (11, 29.7%), Klebsiella pneumoniae (10, 27%), Citrobacter freundii (3, 8.1%), Salmonella enterica serovar Typhi (3, 8.1%), etc. The majority of Enterobacteriaceae isolates were susceptible to piperacillin-tazobactam and meropenem. As regards Salmonella spp., S. Typhi was isolated from 2 (3.8%) patients in Group A and 1 (16%) in Group C. Antimicrobial susceptibility of potential causative organisms, the severity of the cholecystitis, and the local susceptibility pattern must be taken into consideration when prescribing drugs. A protocol regarding the management of such cases should be formulated based on observations of similar studies.

Diagnosis of pancreaticobiliary malignancy by detection of minichromosome maintenance protein 5 in bile aspirates

Biliary brush cytology is the standard method of sampling a biliary stricture but has a low sensitivity for the detection of malignancy. We have previously shown that minichromosome maintenance (MCM) replication proteins (Mcm2–7) are markers of dysplasia and have utilised these novel biomarkers of growth for the diagnosis of cervical and bladder cancer. We aimed to determine if MCM proteins are dysregulated in malignant pancreaticobiliary disease and if levels in bile are a sensitive marker of malignancy. In 30 tissue specimens from patients with malignant/benign biliary strictures, we studied Mcm2 and -5 expression by immunohistochemistry. Bile samples were also collected prospectively at endoscopic retrograde cholangiopancreatography from 102 consecutive patients with biliary strictures of established (n=42) or indeterminate aetiology (n=60). Patients with indeterminate strictures also underwent brush cytology as part of standard practice. Bile sediment Mcm5 levels were analysed using an automated immunofluorometric assay. In benign biliary strictures, Mcm2 and -5 protein expression was confined to the basal epithelial proliferative compartment – in contrast to malignant strictures where expression was seen in all tissue layers. The percentage of nuclei positive for Mcm2 was higher in malignant tissue (median 76.5%, range 42–92%) than in benign tissue (median 5%, range 0–33%) (P<0.0005), with similar results for Mcm5. Minichromosome maintenance protein 5 levels in bile were significantly more sensitive than brush cytology (66 vs 20%; P=0.004) for the detection of malignancy in patients with an indeterminate stricture, with a comparable positive predictive value (97 vs 100%; P=ns). In this study, we demonstrate that Mcm5 in bile detected by a simple automated test is a more sensitive indicator of pancreaticobiliary malignancy than routine brush cytology.

Bile Aspiration for Diagnosis of Candida glabrata Cholecystitis

Bile Aspiration for Diagnosis of Candida glabrata Cholecystitis

Genetic evidence that apolipoprotein E4 is not a relevant susceptibility factor for cholelithiasis in two high-risk populations

Apolipoprotein E (apoE) isoforms are genetic determinants of interindividual variations in lipid metabolism. To assess whether apoE is a genetic risk factor for cholesterol gallstone disease (GD), we analyzed apoE variants in populations from Chile and Germany, two countries with very high prevalence rates of this disease. ApoE genotypes were determined in Chilean gallstone patients (n = 117) and control subjects (n = 122) as well as in German gallstone patients (n = 184) and matched controls (n = 184). In addition, we studied apoE variants in subgroups of Chilean patients with strong differences in their susceptibility to acquire gallstones: 50 elderly subjects without gallstones in spite of well-known risk factors for this disease (gallstone-resistant) and 32 young individuals with gallstones but without risk factors (gallstone-susceptible). Furthermore, correlation analysis of apoE genotypes with cholesterol crystal formation times, biliary cholesterol saturation index (CSI), and gallstone cholesterol contents was performed in 81 cholecystectomized patients. In this study analyzing the largest sample set available, apoE4 genotype was not associated with an increased frequency of GD in either population. Moreover, in the Chilean population after adjusting for risk factors such as gender, age, body mass index, serum lipids, and glucose, the odds ratio for the association of the apoE4 allele and GD was significantly (P < 0.05) <1. Also, genotypes were not correlated with cholesterol crystal formation time, CSI, or gallstone cholesterol content. In contrast to previous smaller studies, apoE polymorphisms were not associated with susceptibility to cholesterol GD in high-risk populations.

Cholangitis mit hepatischen Mikroabszessen durch Salmonella enterica Serovar Choleraesuis

A 71-year-old man was admitted to the emergency unit of another hospital with a mild gastroenteritis and high fever. On admission g-GT and C-reactive protein (CRP) levels were markedly elevated. Under nonspecific antibiotic therapy with ampicillin/sulbactam the fever persisted and for the first time, on day 5, the patient complained of right-sided abdominal pain. An increase in the laboratory values indicated cholestasis. After changing the antibiotics to ceftriaxon and metronidazole, acute cholangitis being suspected, the fever subsided immediately and the CRP level decreased. The patient was discharged after seven days of antibiotic treatment. But he was once more admitted after four weeks to another hospital because of severely reduced general condition and mild fever. He was transferred to our unit after two weeks. The test values indicated cholestasis and CRP was markedly elevated, while aminotransferase activity was slightly increased and normocytic normochromic anemia developed. Viral hepatitis, autoimmune and metabolic liver diseases, toxic liver damage, extrahepatic cholestasis and an endocarditis were excluded. Bile was aspirated by endoscopic retrograde cholangiopancreatography and added to blood culture bottles. Salmonella enterica serovar choleraesuis var. Kunzendorf was isolated. The patient was treated with ciprofloxacin, 2 x 250 mg by mouth for a total of five weeks. After 17 days of treatment no Salmonella bacteria were grown from a newly aspirated bile sample and the patient became free of fever. Salmonella infections do not always present as gastroenteritis. Bacteremia should be considered in the differential diagnosis of such infections. If cholangitis persists, the aspiration of bile for microbiological tests can be a rational diagnostic step and facilitates treatment. Prolonged administration of antibiotics is necessary to avoid relapse. and follow-up is very important when treatment is finished.

Diagnosis of Pancreaticobiliary Malignancy By Detection of Minichromosome Maintenance 5 Protein in Bile Aspirates

Introduction: Brush cytology (BC) is the most commonly used method of sampling a biliary stricture but has a low sensitivity (20-40%) for the detection of malignancy. We have shown that minichromosome maintenance (Mcm) replication proteins can be utilised as novel proliferation markers for the diagnosis of cervical and bladder cancer (1,2). Aims & Methods: To determine if Mcm proteins are dysregulated in malignant pancreaticobiliary disease and their detection in bile is a sensitive marker of malignancy. In 30 biopsy/resection specimens from malignant/benign biliary strictures we studied Mcm expression by immunohistochemistry. Bile aspirates were collected prospectively from 102 consecutive patients (mean age 66 yr, range 33-103 yr; M:F 1:1) with biliary strictures of established (n = 42) or indeterminate aetiology (n = 60). Biliary Mcm 5 levels were analysed in a blinded fashion using monoclonal anti-human Mcm 5 antibodies in an automated immunofluorometric assay. Patients with indeterminate strictures also underwent BC as part of standard practice. A diagnosis of malignancy was made by positive cytology/biopsy, or evidence of disease progression on imaging. Benign disease was based on negative pathology during a median 22 (range 6-32) months follow-up. Results: In benign biliary strictures, Mcm protein expression was confined to the basal epithelial proliferative compartment - in contrast to malignant strictures where expression was seen in all tissue layers. The percentage of nuclei positive for Mcm protein was higher in malignant tissue (median 76.5%, range 42-92%) than in benign tissue (median 5%, range 0-33%) (p < 0.0005). Amongst the 102 patients, 63 (62%) had malignant disease: cholangiocarcinoma (n = 28) pancreatic cancer (n = 23), or other malignancies (n = 11). Benign strictures (n = 39) were attributed to gallstone disease (n = 14), primary sclerosing cholangitis (n = 9), or other conditions (n = 16). Operating characteristics at maximal sensitivities for mcm 5 in bile and BC sampled from the 60 indeterminate strictures are given in Table 1. The sensitivity and specificity of Mcm 5 test in strictures with established diagnoses was 62% and 92% respectively. Conclusion: Elevated levels of Mcm 5 in bile are significantly more sensitive than brush cytology for the diagnosis of pancreaticobiliary malignancy, with a comparable specificity.REFERENCES: 1. Williams et al PNAS 1998 2. Stoeber et al JNCI 2002 Table 1 Sensitivity (95% CI) Specificity (95% CI) PPV (95% CI) NPV (95% CI) Area under curve (95% CI) Mcm 5 cut-off point >1000 66% (50-79) a P = 0.004 Mcm 5 vs cytology 94% (70-100) b p = NS 97% (90-100) 50% (32-68) 80% (70-91) Brush cytology 20% (7-35) a P = 0.004 Mcm 5 vs cytology 100% (75-100) b p = NS 100% 31% (18-44) 60% (40-76) a P = 0.004 Mcm 5 vs cytology b p = NS Open table in a new tab

Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease

Nonsurgical gallbladder drainage has been described according to percutaneous 1 Ito K. Fujita N. Noda Y. et al. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial. AJR Am J Roentgenol. 2004; 183: 193-196 Crossref PubMed Scopus (124) Google Scholar , 2 Tsumura H. Ichikawa T. Hiyama E. et al. An evaluation of laparoscopic cholecystectomy after selective percutaneous transhepatic gallbladder drainage for acute cholecystitis. Gastrointest Endosc. 2004; 59: 839-844 Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar and endoscopic transpapillary approaches. 3 Baron T.H. Farnell M.B. Leroy A.J. Endoscopic transpapillary gallbladder drainage for closure of calculous gallbladder perforation and cholecystoduodenal fistula. Gastrointest Endosc. 2002; 56: 753-755 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Endoscopic transduodenal gallbladder puncture for diagnostic purposes has been described, although with a high risk of bile leak. 4 Jacobson B.C. Waxman I. Parmar K. et al. Endoscopic ultrasound-guided gallbladder bile aspiration in idiopathic pancreatitis carries a significant risk of bile peritonitis. Pancreatology. 2002; 2: 26-29 Abstract Full Text PDF PubMed Scopus (50) Google Scholar

Biliary Tract Candidiasis: Diagnostic and Therapeutic Approaches in a Case Series

Biliary obstruction with its wide range of potential causes is a common disorder in gastroenterology. Infections of the biliary tract with Candida and other fungal species leading to obstructive jaundice have increasingly been recognized in the last few years. Besides a few case reports, there are few data in the literature giving us an idea how to diagnose and treat these patients. We report on a series of seven patients suffering from biliary tract candidiasis who were diagnosed and treated at our institution. Predisposition factors, reliability of various diagnostic modalities, and treatment options based on our own experience are presented and discussed. Besides the general diagnostic modalities such as laboratory findings or ultrasonography, we often observed mycelia in the bile duct system endoscopically. Typical morphological changes in peripheral bile ducts could be detected during endoscopic retrograde cholangiopancreatography (ERCP). Aspiration of bile and subsequent microbiological analysis in combination with ERCP findings revealed diagnosis of bile duct candidiasis in all cases. Treatment included both antiinfectious drugs and endoscopic therapy such as bile duct drainage, lavage, or débridement. With respect to fungal eradication, therapy was successful in 71% of cases as proven by microbiological analysis of bile aspirates. Since many of these patients suffer not only from biliary mycosis but also from disease necessitating immunosuppression, the prognosis was poor in some cases. Biliary tract candidiasis because of immunosuppression is an increasingly recognized disease and remains a major clinical challenge. Besides laboratory analysis and ultrasonography, diagnostic modalities should include aspiration of bile during ERCP and microbiological analysis. Antiinfectious drug treatment as the main therapeutic column for biliary candidiasis should be complemented by endoscopic intervention.

Safety and Efficacy of ERCP in Pregnancy

Purpose: To report our experience with ERCP during pregnancy including safety and efficacy. Methods: A retrospective review of all consecutive ERCPs performed on pregnant patients from October 2001 to May 2006. Results: Three ERCPs were performed on pregnant patients. Two patients presented with cholelithiasis, abnormal liver function tests and dilatation of the biliary tree by abdominal ultrasound. One patient had biliary leak demonstrated by intrabdominal fluid collection on ultrasound after laproscopic cholecystectomy. Two of the three underwent ERCP under general anesthesia and one patient underwent consious sedation supervised by an anesthesiologist. Techniques to minimize fluoroscopy were used including aspiration of bile to identify correct position of the sphincterotome. All patients with choledocholithiasis underwent sphincterotomy with stone extraction. The patient with biliary leak underwent stent placement without sphincterotomy. The procedures were successful in all cases including the biliary leak which resolved completely in two weeks. No complications related to the procedure were identified in the the mother or the babies. Conclusions: ERCP can be performed safely in pregnancy if precautions are taken to minimize radiation exposure.

Bacterial cholangitis/cholangiohepatitis with or without concurrent cholecystitis in four dogs

To evaluate the clinical, clinical pathology, diagnostic imaging, microbiological and pathological features of cholangitis/cholangiohepatitis in the dog. The study design was a retrospective review of cases of bacterial cholangitis/cholangiohepatitis presented to the University of Bristol during the period 1995 to 2000. The diagnosis was made based on hepatic histopathological findings and positive bile culture results. Four dogs met the inclusion criteria. Common presenting signs included anorexia (n=4), jaundice (n=4), vomiting (n=4) and pyrexia (n=2). All four dogs had a leucocytosis or neutrophilia reported at some time in their history along with serum bilirubin elevation. In addition, serum alkaline phosphatase and alanine transaminase activity was increased in all of the dogs in which it was measured both before and at the time of referral. In general, the diagnostic imaging findings were non-specific. Organisms cultured from bile aspirates were Escherichia coli (n=3), Clostridium species (n=2) and a faecal Streptococcus species (n=1). Two cases resolved with medical treatment alone; two with concurrent cholecystitis required cholecystectomy. Following surgery, both of these cases showed a resolution of clinical signs. This report highlights the fact that bacterial cholangitis/cholangiohepatitis with or without concurrent cholecystitis should be considered as a potential differential in dogs presenting with signs referable to biliary tract disease.

Enzymatic Variability of Candida krusei Isolates in a Course of Fungal Infection in a Liver Transplant Recipient

Transplant recipients are at high risk of fungal infections. The main site of fungal infections in patients undergoing liver transplantation is the abdominal cavity. One factor determining the pathogenicity of fungi is their ability to secrete hydrolytic enzymes. The aim of this study was to assess the enzymatic activity of Candida krusei, which caused an infection in a liver transplant recipient. The clinical specimens included swabs of throat, nose, and two drains, as well as bile, stool, and abdominal cavity aspirate. The yeast-like fungi isolated were identified by an ID 32 C test (bioMérieux) and their enzymatic activity assayed with the use of an API-ZYM test. Two biotypes of C. krusei were identified, depending on the source of the clinical specimen. The C. krusei isolates cultured from a throat swab, a nasal swab, and one of the drains secreted esterase lipase C8 (enzyme IV) and valine arylamidase (enzyme VII), in contrast to those isolated from the bile, abdominal cavity fluid, another drain, and stool. Characterization of two biotypes of C. krusei isolates cultured from different clinical samples from several infection sites indicated an ability of C. krusei to adapt to variable environmental conditions.