Biliary Duct Strictures Research Articles

Biliary injuries after pancreatic surgery: interventional radiology management.

Bile duct injuries are among the most feared complications after pancreatic surgery. Most of these surgical complications are related to iatrogenic injuries and include bile leakage, biliary duct obstruction or stricture and infection. A wide range of Interventional Radiology treatment options are currently available. The options include percutaneous transhepatic cholangiography (PTC), percutaneous transhepatic biliary drainage (PTBD), percutaneous balloon dilatation and stenting, image-guided percutaneous abscess drainage. The purpose of this review is to describe the current evidence in this continuously evolving field.

The role of imaging in determining prognosis for primary sclerosing cholangitis: A systematic review

Background/Aims:Primary sclerosing cholangitis (PSC) is a chronic, progressive, fibrotic bile duct disease. Resultant complications include infection, progressive liver disease and cancer. While diagnosis relies extensively on imaging, the role of imaging in determining prognosis is unclear. The aim of this study was to systematically review existing imaging indices and features that predict PSC progression.Materials and Methods:We performed a systematic review of imaging features that predict PSC progression. PubMed, EMBASE, MEDLINE, Clinicaltrials.gov and the Cochrane Library were searched from inception to November 2018 for relevant studies. Pertinent data were extracted and assessed. Study quality was evaluated using the Newcastle-Ottawa scale (NOS).Results:The search returned 2504 results. Nine studies were included in the final review. Four studies evaluated the prognostic value of imaging features and five evaluated prognostic algorithms. The mean NOS score was 4.44 ± 0.98 on a scale of 0 to 9. Imaging features that were of prognostic value were degree of intrahepatic duct narrowing, the presence of a dominant biliary duct stricture and percentage of narrowed intraheptic ducts. Three imaging indices (one endoscopic retrograde cholangiopancreatography (ERCP)-based and two magnetic resonance-based) had been derived. The ERCP index was validated in a second cohort and subsequently updated to improve its predictive ability. The magnetic resonance cholangiopancreatography (MRCP) index was validated in two studies and was found to be predicative of transplant-free survival. A modified MRCP index (MRCP-risk score) was evaluated in a prospective multicenter study and was found to be predicative of PSC-related disease progression.Conclusion:In conclusion, ERCP and MRCP-based indices have short-term prognostic value in PSC. However, more studies are required to validate their predictability of disease-related progression, such as liver decompensation, ascending cholangitis, cholangiocarcinoma and liver transplantation.

Biliary duct stenosis after image-guided high-dose-rate interstitial brachytherapy of central and hilar liver tumors : Asystematic analysis of 102 cases.

Image-guided high-dose-rate interstitial brachytherapy (iBT) with iridium-192 is an effective treatment option for patients with liver malignancies. Little is known about long-term radiation effects on the bile duct system when central hepatic structures are exposed to iBT. This retrospective analysis investigates the occurrence of posthepatic cholestasis (PHC) and associated complications in patients undergoing iBT. We identified patients who underwent iBT of hepatic malignancies and had point doses of ≥1 Gy to central bile duct structures. Patients with known bile duct-related diseases or prior bile duct manipulation were excluded. 102 patients were retrospectively included. Twenty-two patients (22%) developed morphologic PHC after amedian of 17 (3-54) months; 18 of them were treated using percutaneous transhepatic cholangiopancreatography drainage or endoscopic retrograde cholangiopancreatography. The median point dose was 24.8 (4.4-80) Gy in patients with PHC versus 14.2 (1.8-61.7) Gy in those without PHC (p = 0.028). Adose of 20.8 Gy (biological effective dose, BED3/10 = 165/64.1 Gy) was identified to be the optimal cutoff dose (p = 0.028; 59% sensitivity, 24% specificity). Abscess/cholangitis was more common in patients with PHC compared to those without (4 of 22 vs. 2 of 80; p = 0.029). Median survival did not differ between patients with and without PHC (43 vs. 36months; p = 0.571). iBT of liver malignancies located near the hilum can cause PHC when the central bile ducts are exposed to high point doses. Given the long latency and absence of impact of iBT-induced PHC on median survival, the rate of cholestasis and complications seen in our patients appears to be acceptable.

Postprandial bile acid levels in intestine and plasma reveal altered biliary circulation in chronic pancreatitis patients

Bile acid (BA) secretion and circulation in chronic pancreatitis (CP) patients with exocrine pancreatic insufficiency (EPI) were investigated by simultaneously measuring postprandial levels of individual BAs in duodenal contents and blood plasma using LC-MS/MS. CP patients and healthy volunteers (HVs) were intubated with gastric and duodenal tubes prior to the administration of a test meal and continuous aspiration of duodenal contents. Pancreatic lipase outputs in CP patients were very low (0.7 ± 0.2 mg) versus HVs (116.7 ± 68.1 mg; P < 0.005), thus confirming the severity of EPI. Duodenal BA outputs were reduced in CP patients (1.00 ± 0.89 mmol; 0.47 ± 0.42 g) versus HVs (5.52 ± 4.53 mmol; 2.62 ± 2.14 g; P < 0.15). Primary to secondary BA ratio was considerably higher in CP patients (38.09 ± 48.1) than HVs (4.15 ± 2.37; P < 0.15), indicating an impaired transformation of BAs by gut microbiota. BA concentrations were found below the critical micellar concentration in CP patients, while a high BA concentration peak corresponding to gallbladder emptying was evidenced in HVs. Conversely, BA plasma concentration was increased in CP patients versus HVs suggesting a cholangiohepatic shunt of BA secretion. Alterations of BA circulation and levels may result from the main biliary duct stenosis observed in these CP patients and may aggravate the consequences of EPI on lipid malabsorption.

Endoscopic Interventions in Acute Pancreatitis: What the Advanced Endoscopist Wants to Know.

Endoscopic interventions play an important role in the modern management of pancreatic fluid collections. Successful management of pancreatitis is dependent on proper classification of the disease and its local complications. The 2012 revised Atlanta classification divides acute pancreatitis into subtypes of necrotizing pancreatitis and interstitial edematous pancreatitis (IEP) on the basis of the radiologic presence or absence of necrosis, respectively. Local complications of IEP include acute pancreatic fluid collections and pseudocysts, which contain fluid only and are differentiated by the time elapsed since the onset of symptoms. Local complications of necrotizing pancreatitis include acute necrotic collections and walled-off necrosis, which contain nonliquefied necrotic debris and are differentiated by the time elapsed since the onset of symptoms. Endoscopic techniques are used to treat local complications of pancreatitis, often in a step-up approach, by which less invasive techniques are preferred initially with potential subsequent use of more invasive procedures, dependent on the patient's clinical response and collection evolution. Common interventions performed by the advanced endoscopist include endoscopic transmural drainage and endoscopic transmural necrosectomy. However, some collections require a multimodal approach with adjunctive placement of percutaneous drainage catheters or the use of videoscopic-assisted retroperitoneal débridement. Additional endoscopic interventions may be required in the setting of pancreatic or biliary duct stones or strictures. Common complications of endoscopic intervention in the setting of pancreatitis include bleeding, infection, perforation, and stent migration. This article reviews the classification of acute pancreatitis, familiarizes radiologists with the common endoscopic techniques used in its management, and improves identification of the clinically relevant imaging findings and procedural complications related to endoscopic interventions in pancreatitis. ©RSNA, 2018.

Preliminary results of surgical repair of iatrogenic biliary strictures

Introdução: A estenose cicatricial de vias biliares permanece uma complicação crítica de colecistectomias, com consequências devastadoras para o fígado e risco de morte. Objetivo: Avaliar os resultados a longo prazo da correção cirúrgica de lesão iatrogênica de vias biliares realizada em um único centro. Metodologia: Pacientes submetidos a correção cirúrgica de lesão iatrogênica de vias biliares entre 1990 e 2016 foram avaliados retrospectivamente. As informações foram coletadas dos prontuários e da base de dados eletrônica HCMED. Os resultados preliminares foram analisados pela comparação de frequências ou médias aritméticas com desvio-padrão dos parâmetros estudados. Resultados: Foram incluídos 158 casos no estudo, 81% mulheres e com idade média de 45,54 anos. Os sintomas mais frequentemente apresentados foram icterícia (em 79,11% dos casos), dor abdominal (59,49%), colúria (52,53%), acolia ou hipocolia fecal (47,47%), febre (44,3%), prurido (34,18%) e perda de peso (27,22%). A estenose de vias biliares foi secundária a colecistectomia convencional em 63,92% dos casos, a colecistectomia laparoscópica em 22,15%, e a colecistectomia não-especificada em 13,92%. Os pacientes foram divididos de acordo com o diagnóstico de estenose de via biliar (EVB), n=93 casos (58,86%), ou estenose de anastomose bilio-digestiva (EABD), n=65 casos (41,14%). No grupo EVB, níveis de bilirrubina, ALT, AST e GGT eram significativamente mais altos no pré-operatório que no pós-operatório. No grupo EABD, níveis de bilirrubina, AST e GGT eram significativamente mais altos no pré-operatório que no pós-operatório, entretanto não houve diferenças nos níveis de ALT. Recidiva da estenose ocorreu em 5 casos do grupo EVB, e em 7 casos do grupo EABD. A sobrevida no grupo EVB foi de 98,92% em 1 ano e 97,85% em 5 anos; e no grupo EVB, 98,64% e 95,38%, respectivamente. Conclusões: A correção cirúrgica de lesões complexas de vias biliares tem uma taxa de sucesso de 89,87% quando realizada em serviços de referência.

Second generation optical coherence tomography: Preliminary experience in pancreatic and biliary strictures

IntroductionEvaluation of indeterminate biliary strictures remains a diagnostic challenge. Optical coherence tomography (OCT) provides in-vivo, wide-field, cross-sectional imaging at the microstructure level. We present the first preliminary data using a second-generation OCT system using volumetric laser endomicroscopy (VLE) in biliary and pancreatic duct strictures. Methods10 consecutive patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and OCT for indeterminate biliary or pancreatic stricture evaluation were captured in a registry. Following ductal cannulation and guidewire placement, an imaging probe was advanced into the duct and images were interpreted in-vivo. Tissue sampling with cytology brushing was performed in all cases. Demographics, procedural information, imaging data, and histologic findings were collected. Results8 had biliary strictures and 2 had pancreatic duct strictures. VLE was successfully performed in all patients (100%). Histology revealed malignancy in 3 patients (cholangiocarcinoma) and benign disease in the remaining 7 patients, including 1 with primary sclerosing cholangitis (PSC). All 3 cholangiocarcinoma patients demonstrated epithelial thickening with projections, a hyper-reflective surface with shadowing, and layering effacement (loss of visualization and haziness of inner mucosal layers). A PSC patient showed onion skin layering and hyper-reflective sub-surface structures but with preserved wall layering. Benign biliary strictures showed clearly delineated epithelial layer and clear layering in the inner mucosal layers as well as the presence of dilated hypo-reflective structures. ConclusionThere may be characteristic VLE findings for malignant, inflammatory, and benign biliary strictures.

Elevated Liver Enzymes Treated with Nephrectomy: A Case of Stauffers Syndrome

Introduction: Elevated liver enzymes are commonly encountered in clinical practice. Biliary stones, biliary duct strictures and malignant disorders involving the pancreas and hepatobiliary system often cause cholestatic liver disease. Herein, we describe a rare case of cholestasis induced by renal cell carcinoma (RCC). Case Description: A 76-year-old man presented to the emergency department with a 10-day history of right-sided flank pain. Comprehensive metabolic panel revealed an elevated total bilirubin of 1.2 mg/dL, elevated alkaline phosphatase of 242 IU/L, mildly elevated AST of 42 IU/L and normal ALT of 24 IU/L. Abdominal ultrasound demonstrated hepatic steatosis with shadowing and echogenic sludge within the gallbladder without biliary obstruction. Computed tomography of the abdomen and pelvis revealed a large right renal mass measuring 17.2 x 16.3 x 14.4 cm with central necrosis and without metastatic disease. He underwent right nephrectomy with normalization of hepatic enzymes. Pathologic assessment confirmed T3a papillary renal cell carcinoma. Unfortunately, postoperative course was complicated by sepsis and respiratory failure, which resulted in his death. Discussion: This case presents a rare entity, known as Stauffer's syndrome. It is defined as RCC-induced elevation of liver enzymes. It usually manifests with anicteric cholestasis without evidence of biliary duct dilation. A theorized mechanism of cholestasis in Stauffer's syndrome is believed to be secondary to interleukin-6 (IL-6) production from RCC. Patients with RCC and elevated alkaline phosphatase have been found to have significantly higher levels of serum IL-6. Following resection of the tumor, liver function tests normalized, which confirmed the diagnosis of Stauffer's syndrome.Table 1: Lab Values at PresentationTable 2: Lab Values following NephrectomyFigure 1

IgG4-associated cholangiopathy-mimicking Klatskin Tumor – Is surgery justfied in patients with normal IgG4 serum concentrations? A case report

IgG4-associated cholangiopathy is one manifestation of a recently recognized IgG4-associated disease entity characterized by elevated serum IgG4 levels, IgG4 lymphoplasmatic infiltration, and biliary duct strictures thus mimicking cholangiocarcinoma of the hilar bifurcation (Klatskin's tumor). The differentiation between benign strictures of the bile duct bifurcation and Klatskin's tumor is clinically challenging, but of critical importance because of the fundamentally different therapeutic approaches.

ERCP tissue sampling

ERCP tissue sampling

Tu1573 Does Intraductal Aspiration Improve Brushing Adequacy in Biliary Duct Stricture? a Single Center Experience

Tu1573 Does Intraductal Aspiration Improve Brushing Adequacy in Biliary Duct Stricture? a Single Center Experience

OC-111 Diagnostic yield of endoscopic ultrasound (EUS) in the evaluation of idiopathic pancreatitis. a single tertiary referral centre experience

<h3>Introduction</h3> Idiopathic acute pancreatitis (IAP) represents a diagnostic and therapeutic challenge. IAP is prone to high recurrence and understanding its aetiology may assist in preventing recurrent episodes and its related morbidity and mortality. Appropriate investigations help to determine the underlying aetiology and can guide further effective management. We describe our experience to evaluate the role of endoscopic ultrasound (EUS) in patients with unexplained acute pancreatitis in whom cross sectional imaging and conventional laboratory testing had failed to identify the aetiology in a tertiary pancreatico-biliary referral centre. <h3>Method</h3> We retrospectively identified all patients who underwent EUS for assessment of idiopathic acute or recurrent pancreatitis during the period Jan 2007–Dec 2013. All patients had appropriate radiological investigations and no underlying cause identified on transabdominal ultrasound, computed tomography (CT) and on magnetic resonance cholangiopancreatography (MRCP). Patients with risk factors known to precipitate pancreatitis including alcohol excess, medications, metabolic or autoimmune conditions, were excluded. <h3>Results</h3> 44 patients (male 32, female 12) were identified with a mean age of 50 years (range 21–79 years). 33 (75%) patients had recurrent attacks of acute pancreatitis whereas 11 (25%) patients were referred for EUS after a single attack of acute pancreatitis. EUS revealed a cause of pancreatitis in 21/44 (47.7%) patients. Pancreatic duct stones were detected in 10 (22.7%); biliary duct microlithiasis in 4 (9%); pancreatic divisum in 3 (6.8%) and peri-ampullary lesions in 2 (4.5%) patients. One each had a pancreatic duct stricture, biliary duct stricture and one patient was diagnosed with IPMN (intra-papillary mucinous neoplasm). No underlying cause could be found in 23 (52.3%) patients. <h3>Conclusion</h3> EUS demonstrated aetiology in almost half of patients with unexplained acute or recurrent pancreatitis. Our findings support the emerging evidence that EUS is a valuable diagnostic tool in the evaluation of patients with idiopathic pancreatitis and should be considered where initial diagnostic workup including cross sectional imaging remains inconclusive. <h3>Disclosure of interest</h3> None Declared.

Delayed rearterialization unlikely leads to nonanastomotic stricture but causes temporary injury on bile duct after liver transplantation.

Nonanastomotic strictures (NAS) are common biliary complications after liver transplantation (LT). Delayed rearterialization induces biliary injury in several hours. However, whether this injury can be prolonged remains unknown. The correlation of this injury with NAS occurrence remains obscure. Different delayed rearterialization times were compared using a porcine LT model. Morphological and functional changes in bile canaliculus were evaluated by transmission electron microscopy and real-time PCR. Immunohistochemistry and TUNEL were performed to validate intrahepatic bile duct injury. Three months after LT was performed, biliary duct stricture was determined by cholangiography; the tissue of common bile duct was detected by real-time PCR. Bile canaliculi were impaired in early postoperative stage and then exacerbated as delayed rearterialization time was prolonged. Nevertheless, damaged bile canaliculi could fully recover in subsequent months. TNF-α and TGF-β expressions and apoptosis cell ratio increased in the intrahepatic bile duct only during early postoperative period in a time-dependent manner. No abnormality was observed by cholangiography and common bile duct examination after 3 months. Delayed rearterialization caused temporary injury to bile canaliculi and intrahepatic bile duct in a time-dependent manner. Injury could be fully treated in succeeding months. Solo delayed rearterialization cannot induce NAS after LT.

Pancreatic actinomycosis: Possible complication of long-term pancreatic stenting, diagnosed on endoscopic retrograde cholangiopancreatography guided pancreatic duct brushings

AbstractEndoscopic ultrasound guided fine needle aspiration and endoscopic retrograde cholangiopancreatography guided biliary and pancreatic ductal brushings are being used as routine procedures to diagnose mass lesions of the pancreas and stenotic lesions of the biliary ducts and pancreas. We report a rare case of pancreatic actinomycosis in a patient with alcohol-induced chronic pancreatitis with biliary and pancreatic duct strictures and occluded pancreatic stents, diagnosed on pancreatic duct brushings.

Rejection, Recurrence, or Something Else?

Introduction: A 44-year-old man with proctocoletomy and ileal pouch-anal anastomosis for refractory ulcerative colitis in 1999 underwent liver transplant for primary sclerosing cholangitis in 2003. He was doing well on tacrolimus, mycophenolate and prednisone, and warfarin for antiphospholipid syndrome until May 2013, when he was hospitalized with jaundice. Laboratories at that time were AST 682, ALT 685, total bilirubin 21.0, ALP 591, PT 76.4, INR >7.0, and PTT 46. He referred to taking some natural remedies. Drug-induced liver injury and chronic rejection were considered. MRCP showed no evidence of intra- or extrahepatic biliary duct dilation or strictures. Liver biopsy was consistent with acute and chronic rejection. He was treated with IV steroids and immunosuppression, with marked improvement of LFTs. Three months later, he was re-admitted due to marked increase in LFTs and coagulopathy. He was not being compliant with medications. Acute allograft rejection was considered, and he was treated with high-dose IV steroids and immunosuppression. There was improvement in LFTs and coagulation parameters, and he was discharged on prednisone 40 mg daily, mycophenolate 1 gm twice daily, and tacrolimus 3 mg total daily dose. Evaluation for re-transplantation was started. An erythematous lesion was noticed on the patient’s right forearm, which resembled a cellulitis. Chest CT scan revealed a left hilar opacity measuring 4.3 cm. A bronchoscopy with BAL confirmed the diagnosis of Nocardia. IV antibiotics followed by oral Septra were given. Follow-up chest CT showed resolution of previous findings. Jaundice resolved and MELD improved from 18 to 14 after 2 months of antibiotic therapy. Nocardiosis was considered as the cause of his jaundice, and retransplantation was no longer indicated. Disseminated nocardiosis is an opportunistic infection whose clinical presentation varies with the involved organs and usually presents with fever. Few cases of Nocardia in the liver have been reported and the mortality rate in solid organ transplanted patients is very high. In liver-transplanted patients, the cases reported of nocardiosis include infection in lungs, skin, and brain. However, to our knowledge, this is the first case of nocardiosis presenting as severe cholestasis in a liver transplanted patient. It is important to consider this infection in the differential diagnosis of allograft rejection, as early diagnosis can prevent complications such as retransplantation and even death. Disclosure - Dr. Torres, MD - Advisory Board: AbbVie.

Biliary Strictures after Orthotopic Liver Transplantation: Long-Term Results of Percutaneous Treatment in Patients with Nonfeasible Endoscopic Therapy

PurposeThe aim of this study was to evaluate our experience with percutaneous treatment of biliary strictures after orthotopic liver transplantation in adult patients without the endoscopic access possibility and to evaluate the technical outcomes and long-term clinical results of this treatment. Materials and methodsThirty percutaneous procedures were performed in adult liver transplant recipients (13 men, 17 women, mean age 46.4 years) in our institution between 1996 and 2010. Patients were treated with balloon dilatation and biliary duct drainage due to anastomotic stenosis (n = 20), nonanastomotic stenosis (n = 7), or due to stenosis caused by lymphoproliferation (n = 3). The percutaneous procedure was the first line of treatment due to hepaticojejunoanastomosis (n = 18) or after unsuccessful endoscopic therapy (n = 12). ResultsTechnical success was achieved in 27 patients (90%). The remaining three patients only achieved external drainage with subsequent surgery. There were two complications (6.3%). Long-term clinical success, defined as the absence of clinical, laboratory, or sonographic signs of stricture recurrence was achieved in 22 patients (73.3%) for a mean follow-up of 5.8 years. ConclusionPercutaneous treatment—balloon dilatation and biliary duct drainage—is a first-line option to manage biliary duct strictures in liver recipient, when endoscopic treatment is not possible or unsuccessful. It has a high technical success rate and low complication rate with favorable long-term results.

Abstract No. 372: Animal models in interventional radiology

Animal models are useful for testing and development of devices and drugs, including efficacy, safety and creation of disease models. Our objective is to present the criteria for animal selection including the anatomic similarities to humans, vascular system size, coagulation parameters and reproduction of diseases and problems affecting humans. Twenty-one animal studies were retrospectively reviewed looking into the type of study, type of animal used, utilization of temporary or permanent device, drug or cell therapy and simulation of human diseases. The animals used were swine, canine and rodents. Devices tested included stents in the peripheral circulation and carotids, covered stents in the peripheral circulation and abdominal and thoracic aortic aneurysm model, angioplasty balloons, thrombectomy devices, IVC filters, venous valves, embolic materials, including particles, spheres and several types of coils. Drugs for angiogenesis and coagulation were also tested. Liver and kidney ablation with a variety of devices were performed. Human disease simulation included creation of renal artery stenosis, IVC stenosis, ureteral and biliary duct stenosis. Large animals such as swine were adequate for testing human size devices, such as stents, balloons, IVC filters, thrombectomy and venous valves, however, exuberant fibrin formation and intimal hyperplasia posed problems for permanent implants. Embolic materials can be tested in any size animal simulation of human diseases are best tested in larger animals. Drug therapy and angiogenesis can use medium size animals or large size animals. Simulation of AAA and pseudoaneurysms is better executed in medium to large size animals. The capacity of fibrin development and intrinsic fibrinolytic mechanisms are variable among animals used for research and the animal model needs to match the device to be tested. Several examples will be presented. Animal models are useful for training and for the testing and development of interventional radiology devices and drugs. Selection of the animal size, coagulation profile of the animal and anatomy target of the device or drug study is important for the success of the experiment.

Surgical treatment of biliary ductal stricture complicating localized left hepatolithiasis.

To summarize the experience in the clinical treatment of biliary duct strictures complicating localized left hepatolithiasis in the last two decades. A retrospective analysis of 67 cases of biliary duct strictures complicating localized left hepatolithiasis treated in our center in the last two decades was made with regards to each patient's age, gender, results of various preoperative examinations, operative findings, treatment and postoperative courses. The incidence of left hepatic duct (LHD) stricture was 59.8% and that of a left external hepatic duct (LEHD) stricture was 84.0 % and 84.8% respectively, in which a severe degree dominated. Among the operative procedures used in the treatment of LHD strictures, plastic operation plus biliary enteric anastomosis ranks first in frequency (52.2%), with a re-stricture rate of 17.1%. Left lobectomy ranks third (19.4%) with no re-stricture. Simple plastic performance or dilation had a high occurrence rate of re-stricture and usually needed subsequent surgery. Most LEHD strictures were eradicated by lateral segmentectomy or lobectomy, whereas most LMHD strictures were just the opposite. The rate of preoperative diagnosis of LMHD by endoscopic retrograde cholangiography, percutaneous transhepatic cholangiography, computed tomography or intraoperative and postoperative trans-T-tube cholangiography was much lower than that of LEHD or extrahepatic duct. Too much attention paid to LEHD disorders in the treatment of localized left hepatolithiasis potentially results in negligence or omission in LMHD disorders. Malpractice treatments of LHD strictures are important factors affecting the long term results of localized left hepatolithiasis, for which left lobectomy is usually the therapy of choice.

Intravenous Immunoglobulin Treatment Successfully Improved Subacute Progressive Polyradiculoneuropathy with Polyclonal Gammopathy

The present case was an elderly man with a history of gastric cancer, diffuse biliary duct stenosis and liver cirrhosis. He had markedly elevated IgG, suggesting chronic infection or inflammatory changes in the biliary duct. He developed weakness in his arms and became unable to use his hands within one month and 2 weeks later, he had difficulty walking. Based on his progressive disease course, elevated serum IgG, nerve conduction study and enhanced MRI findings, we diagnosed him as suffering from immune-mediated subacute polyradiculoneuropathy with polyclonal gammopathy, which might be related to Guillain-Barré syndrome. Intravenous immunoglobulin (IVIg) was dramatically effective in this patient. In the follow-up 6 months later he was stable and could walk without a cane. Even in patients with polyclonal gammopathy in chronic inflammatory disease of another organ, IVIg may be effective and beneficial for the patients's quality of life.

RETRACTED ARTICLE: Diagnosis of rejection after liver transplantation: use of phosphorus-31 magnetic resonance spectroscopy (31P-MRS)

In vivo hepatic phosphorus-31 magnetic resonance spectroscopy (31)P-MRS) provides non-invasive information about phospholipid metabolism. To delineate (31)P-MRS abnormalities in patients with chronic rejection and to characterize spectral changes by pathology. Sixty-six liver transplant recipients (18 with chronic rejection and 48 with normal graft function) and 38 controls (23 healthy volunteers and fifteen patients with biliary duct stricture) were studied with in vivo (31)P-MRS. All the data and peak values were calibrated and calculated by the software of spectroscopy analysis GE, and the pH values were calculated by the Malloy's formula, then the peak area ratios and altitudes of metabolites relative to adenosine triphosphate (β-ATP)and phosphate (Pi) were measured. (a) The peak area ratios and altitudes of PME and PDE in biliary duct stricture group and chronic rejection group were higher than those of healthy volunteer group and normal graft function group. Patients with chronic rejection had significant differences in the peak area ratios of PME: β-ATP (P < 0.05) and PDE: β-ATP (P < 0.05) and in the altitudes of PME: β-ATP (P < 0.05) as compared with the other groups. (b) The ratios of β-ATP/Pi decreased in biliary duct stricture group, while they increased in chronic rejection group. There was no difference between the four groups. There were similar changes in the ratios of PME/Pi, but there was significant difference between the chronic rejection group and the other three groups. (c) pH values increased in biliary duct stricture group and chronic rejection group, though the difference was not significant with the healthy control group. (d) Histological specimens showed focal loss of hepatocytes, degeneration, and hepatocytic atrophy. (31)P-MRS imaging is valuable in detecting the metabolism of the liver after transplantation, and suggests that further investigation of alterations in the phospholipid metabolism may be a useful future direction of research.