Biliary Amylase Level Research Articles

A Case of High Confluence of Pancreaticobiliary Ducts Which Presented with Acute Cholecystitis

Introduction: High confluence of pancreaticobiliary ducts (HCPBD) is defined as a disease state in which the common channel length is greater than or equal to 6 mm and causes pancreatobiliary or biliopancreatic reflux, but not classified as pancreaticobiliary maljunction (PBM). Case report: A 65-year-old man had an intermittent pain in the right hypochondriac region for 2 weeks. He was diagnosed as acute cholecystitis, and percutaneous transhepatic gallbladder drainage was performed. Amylase level of drained bile from the gallbladder was elevated to 66260 IU/L suggesting of pancreatobiliary reflux. A trans-gallbladder cholangiography revealed a communication between the cystic dilatation of the intraduodenal common bile duct and the pancreatic duct. Endoscopic retrograde cholangiopancreatography (ERCP) could not identify PBM and showed the relatively long common channel with cystic dilatation and the common bile duct (CBD). Pancreatic duct was not shown easily due to the contraction of the sphincter of Oddi in the pancreatobiliary ductal junction. Simultaneous intraductal ultrasonography showed no visible lesions in the CBD. He was diagnosed as having HCPBD. Endoscopic sphincterotomy (EST) was successfully performed to prevent pancreaticobiliary or biliopancreatic reflux which would cause cholecystitis and pancreatitis. After EST, postprandial biliary amylase level in the gallbladder was low (67 IU/L). Later, he underwent laparoscopic cholecystectomy. Although chronic inflammation was observed, there was no cancer tissue in the gallbladder. Until now, he has no recurrence of cholangitis and pancreatitis. Conclusion: EST is a safe and effective treatment for pancreatobiliary or biliopancreatic reflux due to HCPBD. We should remember that HCPBC has a significant risk to develop gallbladder cancer, even though lower than that of PBM. Therefore, it is necessary to follow up patients with HCPBD after EST. The necessity of preventive cholecystectomy is controversial.

Comparative analysis of spherical and fusiform choledochal cyst based on three-dimensional magnetic resonance cholangiopancreatography, biliary amylase, and histopathological examination.

Aims:The aim was to compare biliary amylase, common channel, and gall bladder/liver histopathology between spherical and fusiform choledochal cysts.Materials and Methods:Children undergoing cyst excision with Roux-en-Y hepatico-jejunostomy over a 17 months period were prospectively studied. The common channel was assessed by three-dimensional (3D) magnetic resonance cholangiopancreatography (MRCP).Results:Among 22 patients (spherical = 10, fusiform = 12), there was a higher incidence of spherical cysts in infants (5/7-71.4%) and fusiform cysts in older children (10/15-66.7%) (P = 0.09). Common channel identified in 14 (64%) cases was long (>10 mm) in 5 (38.2%) (one spherical, four fusiform [P = 0.5]) with associated high biliary amylase levels (>500 IU/L) in four (one spherical, three fusiform) (P = 0.05). Exact point of junction of common bile duct with pancreatic duct was visible with coronal half-Fourier-acquisition single-shot turbo spin-echo and 3D sampling perfection with application with optimize contrast using different flip angle evolution sequence using a reformatted plane of axis, particularly coronal, and coronal oblique orientation. Biliary amylase was raised (>100 IU/L) in 4 (40%) in the spherical group, compared to 8 (67%) in the fusiform group. Mean biliary amylase was similar in gallbladder and cyst in spherical but higher in gallbladder in fusiform cysts. Mean biliary amylase was <500 IU/L in 85.7% infants. Five out of 7 infants had liver fibrosis or cirrhosis on histopathology (P = 0.05). There were no dysplastic changes in the gallbladder epithelium.Conclusion:Three-dimensional MRCP delineated the common channel in two-third cases especially in coronal and coronal oblique orientation. The long common channel may have an etiological role in fusiform cysts. Spherical cysts, especially in infants, have a higher incidence of obstructive cholangiopathy.

Pancreatobiliary reflux in individuals with a normal pancreaticobiliary junction: a prospective multicenter study

Pancreatobiliary reflux (PBR) can occur in individuals without pancreaticobiliary maljunction. The aim of this study was to elucidate the incidence of PBR in individuals with a normal pancreaticobiliary junction and its impact on the biliary tree. Data were prospectively collected from 15 centers on 420 patients with a morphologically normal pancreaticobiliary junction who had undergone bile sampling and measurement of the biliary amylase level. We investigated the incidence and predictive factors for high biliary amylase levels (HBAL), as well as the relationship of HBAL with biliary malignancy. Twenty-three patients (5.5%) showed HBAL (≥10,000 IU/L). Univariate analysis showed that risk factors for the elevation of biliary amylase levels were the existence of a relatively long common channel (≥5 mm), acute pancreatitis, and papillitis. Multivariate analysis revealed that only the existence of a relatively long common channel was a significant factor for PBR. Biliary amylase levels in patients with a relatively long common channel were significantly higher than in patients without a long common channel (12,333 vs. 2,070 IU/L, P = 0.001). The incidence of HBAL (P < 0.001), as well as the overall biliary amylase levels (P = 0.007) were significantly higher in patients with gallbladder cancer than in those without gallbladder cancer. The PBR was frequently observed in individuals with a relatively long common channel. Patients showing HBAL with normal pancreaticobiliary junction are at high risk for gallbladder cancer.

The Relationship Between Biliary Amylase and the Clinical Features of Choledochal Cysts in Pediatric Patients

Although the clinical features of choledochal cysts (CC) in different age groups have been widely studied, the causes of differences in clinical features are unknown. To determine the relationship between biliary amylase and the clinical features of CC in pediatric patients, clinical outcomes were compared in two groups with different amylase levels. From May 1995 to August 2010, 80 patients under 18 years old who underwent choledochal cyst excision and hepaticojejunostomy and measurements of biliary amylase levels were allocated to a low-amylase-level group (amylase level < 200 U/L, n = 26) and a high-amylase-level group (amylase level > 200 U/L, n = 54). Their medical records were retrospectively reviewed. The median age was 4 months (range = 17 days-169 months) in the low group and 48 months (range = 22 days-147 months) in the high group (p = 0.008). In the low group, jaundice was the most common symptom, while abdominal pain was the main symptom in the high group. In histological findings, bile duct proliferation and cholestasis predominated in the low group and portal inflammation predominated in the high group. Radiological findings and preoperative laboratory data were also significantly different between the groups. Postoperative complications occurred in the high group only. There was no mortality in either group. This study shows a relationship between biliary amylase level and clinical manifestations in pediatric patients with CC, implying that there are different underlying pathophysiologies with anomalous pancreaticobiliary ductal union (APBDU).

Effect of Pancreatic Biliary Reflux as a Cofactor in Cholecystitis

This study assessed the effect of pancreatico-biliary reflux (PBR) as co-factor in the process of chronic cholecystitis by measurement of the levels of active pancreatic enzyme amylase in gallbladder bile and serum of patients undergoing cholecystectomy. Pancreatic Amylase levels in bile from the gallbladder and serum were measured during surgery in 68 patients with chronic calcular cholecystitis subjected to elective open or laparoscopic cholecystectomy in the National Hepatology and Tropical Medicine Research Institution and Theodore Bilharz Research Institute. Bile amylase was detected in 64 patients (94.1%) indicating pancreatico-biliary reflux. Biliary amylase level ranged from 20-50 IU/L in 42 patients (61.76%), below 20 IU/l in 14 patients (20.59%), over 50 IU/L in 8 patients (11.76%) and undetectable in two patients. According to gallbladder bile amylase, the incidence of Occult PBR in patients operated upon for chronic calcular cholecystitis was 94.1%. The reason should be clarified by further research and wider scale study. Routinely investigating biliary amylase in every patient having cholecystitis can be a method for early detection of precancerous lesions.

Intestinal metaplasia in gallbladder correlates with high amylase levels in bile in patients with a morphologically normal pancreaticobiliary duct

We reported previously that intestinal metaplasia in the gallbladder is strongly associated with expression of caudal-related homeobox transcription factor Cdx2. It has been documented that occult pancreatobiliary reflux, even in the absence of pancreaticobiliary maljunction, is associated with elevated risk of biliary malignancy. We ascertained the correlation between intestinal metaplasia in the gallbladder and occult pancreatobiliary reflux. In 196 patients with a normal pancreaticobiliary ductal arrangement who had undergone laparoscopic cholecystectomy, we performed intraoperative cholangiography and measured amylase levels in bile sampled from the gallbladder. The cutoff value for high cystic amylase was defined as a biliary amylase level higher than the normal upper limit of serum amylase (215 IU/L). We also retrospectively reviewed the cholecystectomized tissue specimens to investigate the presence of intestinal metaplasia and expression of Cdx2. Then, we explored the relationship between intestinal metaplasia in the gallbladder and occult choledocho-pancreatic reflux. Intestinal metaplasia was found in 16.8% (33/196) of the gallbladders. The prevalence of choledocho-pancreatic reflux revealed by intraoperative cholangiography was not significantly different between cases with intestinal metaplasia (5/33, 15.2%) and those without (25/163, 15.3%; P = .81). However, in cases with intestinal metaplasia, the rate of high cystic amylase (13/33, 39.4%) was significantly higher compared with cases without intestinal metaplasia (26/163, 16.0%, P = .005). In conclusion, intestinal metaplasia in the gallbladder is significantly correlated with high amylase levels in bile in patients with a morphologically normal pancreaticobiliary ductal arrangement.

Amylase levels in bile in patients with a morphologically normal pancreaticobiliary ductal arrangement

We investigated the presence of occult pancreaticobiliary reflux in patients with a morphologically normal pancreaticobiliary ductal arrangement by measuring biliary amylase levels and compared histopathological findings of the gallbladder between groups with high and low biliary amylase levels. In 178 patients with a normal pancreaticobiliary ductal arrangement who had undergone endoscopic retrograde cholangiopancreatography (ERCP), we sampled bile from the bile duct and measured amylase levels. Then we compared clinical features and histological findings of the gallbladder between high (HALG) and low amylase level groups (LALG). A high biliary amylase level was observed in 25.8% (46/178) of the patients. The prevalence of a high biliary amylase level was high in patients with gallbladder carcinoma (40%) and in those with choledocholithiasis (28.4%). The level of amylase in bile was high in patients with gallbladder carcinoma, adenomyomatosis of the gallbladder, and chronic cholecystitis. A strong correlation between the levels of amylase and lipase in bile and the dominance of amylase of pancreatic origin in bile were confirmed by isozyme analysis. Thickening of the gallbladder mucosa was a significant manifestation in HALG. Histological examination of the gallbladder mucosa showed that incidences of metaplastic change and atypical epithelium and Ki67-LI in were higher in HALG than in LALG. Occult pancreaticobiliary reflux is observed in a considerable number of ERCP candidates. Those who show an extremely high biliary amylase level, at least, may be at high risk for biliary malignancies.

Gallbladder Carinoma Associated with Pancreatobiliary Reflux: A Hint for Early Diagnosis of Gallbladder Carcinoma

Background: Pancreatobiliary reflux can occur in patients with and without pancreaticobiliary maljunction (PBM), and it may be associated with gallbladder carcinoma. One of the imaging findings that suggest mucosal changes accompanied by pancreatobiliary reflux is diffuse thickening of the hypoechoic inner layer of the gallbladder wall on abdominal ultrasonography that might reflect cellular proliferation of the gallbladder epithelium. The aim of the present study was to detect the patients with gallbladder carcinoma associated with pancreatobiliary reflux at an early stage by examining ultrasonography and bile sampling. Methods: From March 1995 to September 2007, among 186 patients, who had diffuse thickness (> 3mm) of the inner layer of the gallbladder wall and were suspected of having PBM on ultrasonography in our outpatient clinic, 95 patients were subjected to endoscopic retrograde cholangiopancreatography and bile in the common bile duct was sampled. Among them, patients, who had extremely high biliary amylase levels (> 10,000 IU/L), underwent cholecystectomy, and the clinicopathological findings of those patients were examined. Results: Fifty-two patients had biliary amylase levels in the common bile duct above 10,000 IU/L, including 32 with PBM and 20 without PBM. The occurrence of gallbladder carcinoma and that limited within the mucosa was 31% (10/32), 13% (4/32) in patients with PBM, and 40% (8/20), 15% (3/20) in those without PBM. The occurrence of mucosal hyperplasia and dysplasia was 81% (26/32), 53% (17/32) in patients with PBM, and 85% (17/20), 65% (13/21) in those without PBM. Conclusion: Earlier detection of the diffuse thickening of the hypoechoic inner layer of the gallbladder wall associated with pancreatobiliary reflux could lead to earlier management of gallbladder carcinoma, and might improve the poor prognosis of this tumor.

Gallbladder carcinoma associated with occult pancreatobiliary reflux in the absence of pancreaticobiliary maljunction

We herein report a case of gallbladder carcinoma associated with occult pancreatobiliary reflux (PR) in the absence of pancreatobiliary maljunction. A 67-year-old woman was referred to our hospital for the evaluation and treatment of a gallbladder tumor. Ultrasonography and computed tomography showed a nodular lesion in the fundus of the gallbladder, indicating the possibility of a gallbladder carcinoma. Endoscopic ultrasonography showed the nodular tumor and thickness of the surrounding epithelium. Endoscopic retrograde cholangiopancreatography revealed a normal pancreaticobiliary junction without the common channel and a slight dilatation of the common bile duct (15 mm in diameter). An open cholecystectomy and partial resection of the liver bed of the gallbladder with regional lymphadenectomy was performed. A C-tube was inserted from the cut end of the cystic duct into the common bile duct to prevent bile stasis. Biliary amylase and lipase levels sampled in the gallbladder were 2604 IU/l and 775 IU/l, respectively. Biliary amylase level in the bile collected from the C-tube in the common bile duct was 119 550 IU/l on postoperative day (POD) 6 and 22 265 IU/l on POD 12. These observations suggested that PR was present in this patient. The histopathological findings of the resected specimen showed a well-differentiated adenocarcinoma of the gallbladder with invasion to the muscle layer and no metastasis of the resected lymph nodes. A high index of nuclear staining for MIB-I in the cancer cells (about 10%) was exhibited, and a few cells in the normal epithelium also stained positive.

Gallbladder carcinoma associated with pancreatobiliary reflux

To detect the patients with and without pancreaticobiliary maljunction who had pancreatobiliary reflux with extremely high biliary amylase levels. Ninety-six patients, who had diffuse thickness (>3 mm) of the gallbladder wall and were suspected of having a pancreaticobiliary maljunction on ultrasonography, were prospectively subjected to endoscopic retrograde cholangiopancreatography, and bile in the common bile duct was sampled. Among them, patients, who had extremely high biliary amylase levels (>10000 IU/L), underwent cholecystectomy, and the clinicopathological findings of those patients with and without pancreaticobiliary maljunction were examined. Seventeen patients had biliary amylase levels in the common bile duct above 10000 IU/L, including 11 with pancreaticobiliary maljunction and 6 without pancreaticobiliary maljunction. The occurrence of gallbladder carcinoma was 45.5% (5/11) in patients with pancreaticobiliary maljunction, and 50% (3/6) in those without pancreaticobiliary maljunction. Pancreatobiliary reflux with extremely high biliary amylase levels and associated gallbladder carcinoma could be identified in patients with and without pancreaticobiliary maljunction, and those patients might be detected by ultrasonography and bile sampling.

A case of gallbladder carcinoma associated with pancreatobiliary reflux in the absence of a pancreaticobiliary maljunction: A hint for early diagnosis of gallbladder carcinoma

A 62-year-old man with progressive thickening of the gallbladder wall visited our outpatient clinic. The biliary amylase level in the common bile duct was 19,900 IU/L and that of the gallbladder was 127,000 IU/L, although endoscopic retrograde cholangiopancreatography revealed no pancreaticobiliary maljunction. Histology demonstrated a moderately differentiated adenocarcinoma of the gallbladder. Pancreatobiliary reflux and associated gallbladder carcinoma were confirmed in the present case, in the absence of a pancreaticobiliary maljunction. Earlier detection of the pancreatobiliary reflux and progressive thickening of the gallbladder wall might have led to an earlier resection of the gallbladder and improved this patient's poor prognosis.

Severe dysplasia of the gallbladder associated with occult pancreatobiliary reflux

Pancreatobiliary reflux usually occurs in patients with pancreaticobiliary maljunction and can be associated with the occurrence of gallbladder carcinoma. We present the case of a patient with pancreatobiliary reflux despite having a normal pancreatobiliary junction (occult pancreatobiliary reflux; OPBR), in whom the resected gallbladder presented severe dysplasia. The patient, a 61-year-old woman, showed thickness of the gallbladder wall, detected by ultrasonography and computed temography (CT). Her biliary amylase level in the common bile duct was 103,000 IU/l, and in the gallbladder it was 153,500 IU/l, although endoscopic retrograde cholangiopancreatography revealed a normal pancreaticobiliary junction. Immunohistochemical staining showed many p53-positive nuclei in the dysplastic lesion, and about 50% of the dysplastic cells exhibited diffuse nuclear staining for Ki-67. In the present patient, early diagnosis of occult pancreatobiliary reflux led to early detection of a precancerous lesion of the gallbladder mucosa.

Histologic and Genetic Analysis of the Gallbladder in Patients with Occult Pancreatobiliary Reflux

Purpose: Recent studies have suggested that pancreatobiliary reflux occurs not only in patients with pancreaticobiliary maljunction (PBM), but also in patients without PBM and thereby possibly causes biliary tract disease. In this study, we examined prospectively histological findings and genetic analysis in the noncancerous epithelium of the gallbladder in patients with high biliary amylase levels and a normal pancreaticobiliary junction. Subjects and Methods: Twenty-one patients including nine high biliary amylase levels (HBA) patients with gallbladder diseases for which cholecystectomy was performed, prospectively underwent ERCP to assess confluence of pancreaticobiliary ducts in comparison with biliary amylase levels in the gallbladder in our hospital from October 2002 to November 2003.

Histologic and genetic analysis of the gallbladder in patients with occult pancreatobiliary reflux

Recent studies have suggested that pancreatobiliary reflux occurs not only in patients with pancreaticobiliary maljunction (PBM), but also in patients without PBM and thereby possibly causes biliary tract disease. In this study, we examined prospectively histological findings and genetic analysis in the non-cancerous epithelium of the gallbladder in patients with high biliary amylase levels and a normal pancreaticobiliary junction. Ki-67 L.I of non-cancerous epithelium was 14.4 and 3.5% in the high biliary amylase levels (HBA) group and the low biliary amylase levels (LBA) group, respectively (p<0.01). There was no case showing p53 overexpression regardless of amylase levels of bile. COX-2 expression was detected in the cytoplasm of non-cancerous epithelium in 9 cases in the HBA group and 5 cases in the LBA group. The positive rate of COX-2 overexpression was significantly higher in the HBA group than in the LBA group (p<0.05). COX-2 overexpression cases showed higher Ki-67 L.I than COX-2 non-overexpression cases (21.2 vs. 7.9%, p<0.05). Mutations of the K-ras gene were detected in non-cancerous gallbladder epithelium in 3 cases, only in the HBA group. Patterns of K-ras mutation at codon 12 were GAT in two cases and GTT in one case. Three cases showing COX-2 overexpression also showed K-ras mutation. These three cases showing K-ras mutation had comparatively high cellular proliferative activity (28, 26 and 14%). In conclusion, our data suggest that occult pancreaticobiliary reflux, especially with high biliary amylase levels, represents an important risk factor for the development of gallbladder carcinoma as well as PBM, and it may be possible to detect patients with such high biliary amylase levels by ERCP.

Amylase level in extrahepatic bile duct in adult patients with choledochal cyst plus anomalous pancreatico-biliary ductal union

To investigate the relationship between pancreatic amylase in bile duct and the clinico-pathological features in adult patients with choledochal cyst and anomalous pancreatico-biliary ductal union (APBDU). From 39 patients who underwent surgery for choledochal cyst between March 1995 and March 2003, we selected 15 adult patients who had some symptoms and were radiologically diagnosed as APBDU, and their clinico-pathological features were subsequently evaluated retrospectively. However, we could not obtain biliary amylase in all the patients because of the surgeon's slip. Therefore, we measured the amylase level in gall bladder of 10 patients and in common bile duct of 11 patients. Levels of amylase in common bile duct and gall bladder ranged from 11,500 to 212,000 IU/L, and the younger the patients, the higher the biliary amylase level (r = -0.982, P<0.01). Pathologically, significant correlation was found between the size of choledochal cyst and the grade of inflammation (r = 0.798, P<0.01). And, significant correlation was found between the level of amylase in gall bladder and the grade of hyperplasia. On the other hand, there was no correlation to the age of symptomatic onset or inflammatory grade (r = 0.743, P<0.05). Level of lipase was elevated from 6,000 to 159,000 IU/L in bile duct and from 14,400 to 117,000 IU/L in the gall bladder; however, there was no significant correlation with age or clinico-pathological features. The results support the notion that amylase has a particular role in the onset of symptoms, and suggest that a large amount of biliary amylase induces early onset of symptom, thereby making early diagnosis possible.

Assessment of occult pancreatobiliary reflux in patients with pancreaticobiliary disease by ERCP

The aim of this study was to evaluate the degree of occult pancreatobiliary reflux by measuring the biliary amylase levels in the common bile duct (CBDA) and gallbladder (GBA) at endoscopic retrograde cholangiopancreatography (ERCP). Eligible patients included 86 consecutive cases of pancreaticobiliary disease with prospective implementation of bile collection during an ERCP procedure. Patients with pancreatobiliary maljunction (PBM) were excluded. Nineteen cases of eligible patients had simultaneous collection of gallbladder bile. Bile was further collected by cholecystectomy in 8 cases. Twenty-two cases (26%) revealed a CBDA level higher than serum amylase (high bile amylase level, HBA group) and 64 cases exhibited a CBDA level lower than serum (LBA group). The mean values of CBDA in the HBA and LBA groups were 5502 IU/l and 29 IU/l, respectively. The rate of HBA was significantly higher in patients who were elderly, had a dilated common bile duct, and those with choledocholithiasis (P <0.05). Three cases (16%) showed a CBDA greater than twice the GBA. Eleven cases (58%) exhibited a GBA higher than the CBDA. The values of GBA obtained during ERCP and cholecystectomy were consistent. These findings suggest that even non-PBM cases can exhibit occult pancreatobiliary reflux, which can thereby cause biliary disease.

Occult Pancreatobiliary Reflux and Associated Mucosal Changes of the Gallbladder

Occult Pancreatobiliary Reflux and Associated Mucosal Changes of the Gallbladder Jin Kan Sai, Masafumi Suyama, Yoshihiro Kubokawa, Hiroyuki Tadokoro, Nobuhiro Sato Purpose: To investigate pancreatobiliary reflux in individuals with a normal pancreatobiliary junction and assoicated mucosal changes of the gallbladder. Methods: A total of 108 patients, who had diffuse thickness of the gallbladder wall detected by ultrasonography and normal pancreatobiliary junction on ERCP, were examined for their pathological findings and biliary amylase levels. Results: Nine patients showed biliary amylase levels more than 10,000 IU/L, in whom 4 patients had carcinoma, 2 patients had dysplasia, and 2 patients had hyperplasia of the gallbladder. In contrast, none of the patients with biliary amylase levels less than 1,000 IU/L, had dysplasia nor hyperplasia of the gallblader. Conclustion: Pancreatobiliary reflux can occur in patients with a normal pancreatobiliary junction and induce cancerous and pre-cancerous lesion of the gallbladder.

Occult pancreatobiliary reflux in patients with a normal pancreaticobiliary junction

Background: The aim of this study was to investigate pancreatobiliary reflux in individuals with a normal pancreaticobiliary junction. Methods: Seventy-four patients with a normal pancreaticobiliary junction, as determined by ERCP, underwent secretin injection MRCP before cholecystectomy. Based on changes in the diameter of the biliary system after secretin injection, patients were categorized into enhanced or nonenhanced groups. Results: Biliary amylase was measured in the 4 patients allocated to the enhanced group and 60 in the nonenhanced group. The mean (SD) biliary amylase level in the gallbladder was 123,723 (115,125) IU/L in the enhanced group and 238 (507) IU/L in the nonenhanced group (p < 0.0001). The mean (SD) biliary amylase level in gallbladders with carcinoma (n = 7) was 68,281 (106,500) IU/L, which was significantly higher than that in gallbladders without carcinoma (p < 0.01). Conclusion: Pancreatobiliary reflux similar to that seen in patients with pancreaticobiliary maljunction can occur in individuals with a normal pancreaticobiliary junction and may be associated with carcinoma of the gallbladder. Secretin injection MRCP is useful for identifying these individuals. (Gastrointest Endosc 2003;57:364-8.)

Gallbladder cancer with a low junction of the cystic duct or an anomalous pancreaticobiliary junction.

To evaluate conditions similar to those of carcinogenesis of the gallbladder between the gallbladder with a low junction of the cystic duct (LJCD) and an anomalous pancreaticobiliary junction (APBJ). Retrospective and clinicopathological analysis of patients with gallbladder carcinoma. First Department of Surgery, Kansai Medical University. Examination of 47 patients (7 men and 40 women; average age: 67.8 years) with gallbladder carcinoma revealed 7 patients (14.9%; 1 man and 6 women; average age: 67.8 years) with LJCD and 6 patients (12.8%; 6 women; average age: 60.3 years) with APBJ. Clinical findings in both groups were compared with those of the 34 patients who remained after exclusion of the data of the above 7 patients with LJCD and 6 patients with APBJ. The data of the three groups were examined by the chi 2 test at the 5% level of significance. Most of the gallbladder cancer patients with LJCD or APBJ had gallstones. The biliary amylase levels determined in the gallbladder of patients with LJCD or APBJ were remarkably high. The results indicate that patients with LJCD or APBJ are more likely to develop carcinoma of the gallbladder. The factors responsible for carcinogenesis may be alteration of the bile content due to reflux of pancreatic enzymes through the LJCD or APBJ, and mechanical irritation due to gallstones. Therefore, these pathological conditions in patients with LJCD are similar to those experienced in patients with APBJ.

AN EXPERIENCE WITH A CASE OF THE ANOMALOUS ARRANGEMENT OF PANCREATICOBILIARY DUCTAL SYSTEM UNACCOMPANIED BY BILE DUCT DILATATION WITH REPEATED CHOLANGITIS, PANCREATITIS AND OBSTRUCTIVE JAUNDICE FOLLOWING CHOLECYSTECTOMY

Diagnosis of the anomalous arrangement of pancreaticobiliary ductal system unaccomanied by a dilatation of the bile duct can be difficult, and its treatment is controversial, some favoring only a follow up after the treatment for the concurrent gallbladder lesion and others advocating a dissociative operation.We recently experienced a case in which non-calculous suppurative cholangitis and obstructive jaundice occurred respectively at 5 months and 12 months after cholecystectomy, and the anomalous arrangement of pancreaticobiliary ductal system then diagnosed was successfully treated by dissociative operation.In this case the common bile duct was 8 mm in external diameter and the common channel was 10 mm in length. However, the common bile duct joined the pancreatic duct to form an inverted T, cholangiography readily visualized the pancreatic duct, and the biliary amylase level was elevated, from which the intermediate type of anomalous arrangement of pancreaticobiliary ductal system, proposed by Komi, was diagnosed.Dissociative operation is indicated in the anomalous arrangement of pancreaticobiliary ductal system unaccompanied by bile duct dilatation, if such symptoms as cholangitis, pancreatitis and obstructive jaundice occur repeatedly.