Biliary Tract Pathology Research Articles

Diffuse biliary tract injury after orthotopic liver transplantation

An unusual type of diffuse biliary tract injury after liver transplantation that is characterized by multiple intrahepatic biliary strictures, ductal dilatations, fluid collections, or intrahepatic abscesses has been identified. Over a 5-year period, a total of 10 patients (2%) developed diffuse intrahepatic biliary injury with established vascular patency and no obvious source for their biliary tract pathology. All patients received livers preserved in University of Wisconsin solution with a mean preservation time of 16 hours. This biliary tract injury was associated with the presence of severe preservation injury and Roux limb biliary reconstruction. Of the 10 patients, 5 were treated nonoperatively with multiple stricture dilations and stent placements, 3 underwent retransplantation, 1 was treated operatively with hepaticojejunostomy, and 1 died of sepsis. This study suggests that this complication appears to be related to preservation injury and that the etiology may be ischemic in origin.

Asymptomatic primary sclerosing cholangitis treated with ursodeoxycholic acid

Ursodeoxycholic acid treatment (600 mg/day) was evaluated in a patient with asymptomatic primary sclerosing cholangitis. Serum levels of biliary enzymes decreased to normal ranges within 1 month's treatment and remained normal for 26 months. Serum chenodeoxycholic acid had been replaced by ursodeoxycholic acid, and hepatic copper metabolism, assessed by x-ray probe analysis, improved during the treatment. However, neither biliary tract sclerosis nor portal tract pathology changed with the treatment. These observations suggest that ursodeoxycholic acid protects the liver in primary sclerosing cholangitis by improving the metabolism of bile acid and copper.

Gall Bladder And Common Bile Duct Stones – When Is Direct Cholangiography Indicated?

The medical records of 277 consecutive patients who underwent cholecystectomy for benign gall stone disease, were reviewed to determine the incidence and cause of biliary tract obstructuion. Obstructive jaundice (icteric obstructive biliopathy) was present in 38 cases. This was due to choledocholithiasis in 22, Mirizzi's Syndrome in two, biliobiliary fistula in eight and biliary stricture in five patients. Preoperative direct cholangiography (ERCP/PIC) was helpful. Anicteric patients were classified on the basis of a history of jaundice, serum alkaline phosphatase, sonography and operative findings. Anicteric patients with evidence of biliary tract pathology (anicteric obstructive biliopathy) had a significant incidence of choledocholithiasis (33.3% ). Biliary complications were uncommon in this group (4.3%). Peroperative cholangiography was carried out and was valuable in these patients but was normal in all 83 patients who had no evidence of biliary obstruction.

Clinical and Experimental Studies on the Biliary Tract Pathology in Cases of Abnormal Pancreatico-Choledocho-Ductal Junction, Especially Concerning the Occurrence of Biliary Tract Carcinoma

Clinical and Experimental Studies on the Biliary Tract Pathology in Cases of Abnormal Pancreatico-Choledocho-Ductal Junction, Especially Concerning the Occurrence of Biliary Tract Carcinoma

Use of anapriline for radiopaque diagnosis of sphincter Oddy spasm

Many researchers point to frequent lesion of the sphincter apparatus of the terminal choledochal region in biliary tract diseases. Thus, spastic state of Oddi sphincter occurs in 4.2-21.9% of cases that depends on a contingent of patients and type of biliary tract pathology.
 Diagnostics of spastic state of Oddi sphincter is based on dynamics of contrast substance accumulation, and also on reaction to spasmolytic drugs: nitroglycerin, amylnitrite etc. Nitroglycerin and amyl nitrite are antispasmodics, indirectly acting on smooth muscles of biliary tracts and having unstable effect.
 Based on observation of O.S. Kochnev and V.N. Biryaltsev about the influence of -adrenoblocker anapriline on the contractile function of Oddi sphincter (author's certificate No 1082404), we used this drug in the process of infusion cholangiography in 80 patients with biliary system pathology.

Results of surgical treatment of pancreonecrosis

We analyzed the results of surgical treatment of 128 patients (66 men and 62 women) with various forms of pancreatic necrotic process not associated with biliary tract pathology. There were 76 patients aged from 29 to 60 years old and 52 patients over 60 years old. Past medical history showed that 27 patients had alcoholism, 15 patients - gastric and duodenal ulcer, 16 - heart and vascular diseases; 23 patients had acute or chronic pancreatitis.

Intrahepatic Versus Extrahepatic Cholestasis: Discrimination With Biliary Scintigraphy Combined With Ultrasound

Biliary scintigraphy and ultrasound imaging were performed in 52 patients with suspected biliary tract pathology. Results were correlated with the findings of direct cholangiography. Several new innovations in scintigraphic technique were used. The combination of ultrasound imaging and scintigraphy correctly identified biliary tract obstruction in 17 of 19 patients, 12 of whom had dilated bile ducts on ultrasonography. Intrahepatic cholestasis was correctly diagnosed in 11 of 13 patients. Accurate discrimination between intrahepatic and extrahepatic cholestasis was achieved in 28 of 32 patients (88%) with the combined studies. Scintigraphy also provided a correct diagnosis of acute cholecystitis in all 9 patients with surgically confirmed disease. Eleven additional patients with gallbladder or pancreatic disease had normal bile ducts at scintigraphy, which was confirmed with cholangiography. When combined with ultrasound imaging, modern biliary scintigraphy can (a) provide excellent discrimination between intrahepatic and extrahepatic cholestasis and (b) help determine the need for subsequent invasive diagnostic studies in selected patients.

Bacteriological study of transhepatically aspirated bile. Relation to cholangiographic findings in 295 patients.

The purpose of this study was to elucidate the frequency of bacterial infection of intrahepatic bile in relation to biliary tract pathology. Bile was aspirated during percutaneous transhepatic cholangiography, with or without combined biliary tract drainage, and subjected to bacteriological investigations in 295 patients with various hepatobiliary diseases. Bile was infected in 89% of the 92 patients who had high fever and were on antibiotics at the time of study. Positive cultures were obtained in 39% of the patients who were not so ill as to require antibiotics. The overall incidence of biliary infection was 90% in bile duct stones, particularly high in patients with primary intrahepatic stones, regardless of the presence of stones in the common bile duct, and in patients who had dilation of the common bile duct, presumably due to obstructive involvement of the ampulla of Vater. E. coli and Klebsiella were the most frequent among the aerobic species isolated, and mixed infection involving these organisms was common. Anaerobes were much less frequent, always mixed with aerobes, but positive cultures would increase with more rigorous anaerobic conditions for culture. Duodenal fluid collected simultaneously did not always grow the same microorganisms, but showed a 86-87% coincidence with intrahepatic bile in terms of positive or negative cultures. It is recommended that bile be cultured at the time of percutaneous transhepatic cholangiography.

Gallstone pancreatitis: biliary tract pathology in relation to time of operation.

During a 29-month trial, 65 patients with acute gallstone pancreatitis were randomly selected for biliary tract explorations either within 73 hours of admission (36 patients) or at three months following remission with nonoperative measures (29 patients, with five others awaiting elective operation). The details of surgery were identical, i.e., cholecystectomy, transduodenal sphincteroplasty, and pancreatic duct septotomy. Major bile ducts were cleared of stones by Fogarty catheter passage up the sphincteroplasty. At early operation, pancreatitis was in the acute edematous form in 29 patients, necrotizing in six, and hemorrhagic in one. Acute inflammatory changes were also noticed in three patients who underwent late operation. The locations of the gallstones in patients undergoing early versus delayed operations were, respectively: 97% and 100% in gallbladder, 75% and 28% within common or hepatic ducts (p < 0.02), and 31% and 0% free in duodenum (p < 0.01). The distal choledochus and ampulla were inflamed in 89% of the patients who underwent early operations, but in merely 17% operated upon electively (p < 0.01). Concomitant acute cholecystitis was present in 31% of the patients if surgery was performed during the initial admission, but in only 3% of the patients at delayed operation (p < 0.05). Most striking was the sudden "gush" of pancreatic juice when the ampullary sphincter was first stretched or cut during sphincteroplasty at early operation. Precipitous falls in serum amylase levels then followed over the next 24 hours. No significant differences were noticed in the mortality rate (one death after early operation, two after a delayed procedure), major morbidity rate (in four and three patients, respectively), or in duration of the initial hospitalization period (early operation: 13.5 days, delayed operation: 16.7 days). However, a second admission to the hospital for the delayed operation (12.1 days) was avoided by early operation. These data support the concept that biliary pancreatitis is probably initiated by gallstone passage through, or lodgement at, the ampulla of Vater. The resultant ampullary edema with or without gallstone impaction appears to be the anatomic cause for major pancreatic duct obstruction and the consequent pancreatitis. Early and appropriate surgical relief of the biliary tract pathology via a transduodenal sphincteroplasty can obviate the need for a second admission to the hospital without increasing, significantly, the attendant morbidity and mortality rates.

Significance of intraoperative fibercholangioscopy in the diagnosis of biliary tract disorders.

Intraoperative fibercholangioscopy allows direct inspection of the entire biliary tree up to the secondary distributaries. In 100 patients with suspected biliary tract pathology on account of endoscopic retrograde cholangiography the following findings were obtained: choledocholithiasis (solitary or multiple) in 66, biliary mud in 4, stricutres in 15, common bile duct carcinoma in 8, choledochal cyst in 1 and extrinsic lesions in 6. Peroral direct transpapillary cholangioscopy is still in an experimental stage but its results are promising.

The first application of transhepatic cholangiography to the localization of liver or biliary tract pathology: Hanoi, 1937.

The first application of transhepatic cholangiography to the localization of liver or biliary tract pathology: Hanoi, 1937.

Consequence of selective proximal vagotomy in biliary tract pathology

Recently selective proximal vagotomy has been supplanting truncal vagotomy as a method of choice for peptic ulcers because of its effectiveness in lowering gastric acidity while lessening pyloric spasm. However, its postoperative consequence has not been fully investigated. In the present communication, lithogenic tendency of bile after selective proximal vagotomy has been studied using solubility of human gallstone inserted in dog gallbladder and change in bile composition. The result indicated that after selective proximal vagotomy gallstone incidence is not likely to increase which has been one of the major drawbacks of truncal vagotomy.

Present status of intravenous cholangiography.

PRESENT STATUS OF INTRAVENOUS CHOLANGIOGRAPHYLUIS O. MARTINEZ, M.D., MANUEL VIAMONTE, JR., M.D., PHILLIP GASSMAN, M.D. and LINO BOUDET, M.D.Audio Available | Share

A REVIEW OF TRANSJUGULAR CHOLANGIOGRAPHY

1. Percutaneous transjugular cholangiography can be successfully performed by puncture across the wall of an hepatic vein. Laceration of the liver capsule and entry into the peritoneal cavity can be avoided, thereby eliminating the threat of bile peritonitis and alleviating the necessity for immediate surgery in patients with biliary obstruction. 2. Fifty-six percutaneous transjugular cholangiograms have been attempted, with an over-all success rate of 75 per cent. Successful visualization of the bile ducts in 88 per cent of patients occurred when biliary tract pathology was present. 3. Five serious febrile reactions have occurred, including one death due to gram negative septicemia. However, since patients have been receiving prophylactic antibiotics, there have been no serious complications attributed to this technique. 4. This new anatomic approach to cholangiography lends itself to other applications presently under investigation.

Cine cholangiography: some physiologic observations.

Cholangiography is an important postoperative study in the patient who has had biliary tract surgery. Traditionally, the passage of contrast material has been evaluated by spot-films or other static radiographs, although recently cine studies have been used (4–6). Since the biliary tree is dynamic, x-ray motion studies offer definite advantages in the analysis and evaluation of physiology and pathology especially with respect to the flow and emptying of bile. The purpose of this paper is to report some of the physiologic actions observed in 32 cine cholangiographic studies performed at the Massachusetts General Hospital, Boston, Mass. Anatomy The common bile duct, which is formed by the union of the cystic and common hepatic ducts, is primarily composed of fibroelastic tissue with a minimal amount of smooth muscle fibers. The ampulla of the common duct, however, is composed predominantly of smooth muscle fibers forming the sphincter of Oddi. These smooth muscle fibers act not only as the choledochal sphincter but, extending a short distance up the pancreatic duct, also as the pancreatic duct sphincter (3, 7). Materials and Methods The cine studies were performed between the seventh and sixty-fifth postoperative day in patients ranging in age from eight months to eighty-nine years. All studies were undertaken in the supine position, often with the addition of oblique and prone views. Hypaque 50 under gravity pressure at a height of 15 to 30 cm above the midplane of the body was infused through the indwelling T-tube or cholecystostomy tube. Cine recording was at 7 1∕2 frames per second, although 15 and 30 frames per second were occasionally employed. Thirty patients had T-tubes in the common duct, and in 2 cholecystostomy catheters drained the gallbladder. Since there had been no disease of the common duct in the 2 patients with cholecystostomy, no common duct exploration had been performed and there was no T-tube in it. One patient was operated upon for jaundice which was later considered due to viral hepatitis; in the other, inflammatory changes near the gallbladder were secondary to duodenal ulcer. These two examinations therefore served as “normal” baseline studies for the evaluation and analysis of the ampulla in other cases in which biliary tract pathology had been found at surgery. Observations Both intrahepatic ducts filled without impedance in all patients except the one with hepatitis, in whom hepatic swelling probably caused compression of the ducts. Intrahepatic duct filling was apparently influenced by gravity, for usually the supine position resulted in complete filling of only those ducts in the right lobe, which is more dependent in this position than the left. In the prone position, however, the dependent left ducts filled and the right ducts emptied.

The value of diagnostic non-surgical biliary drainage as compared with cholecystography

1. Non-surgical biliary drainage is a useful diagnostic procedure. 2. It compares favorably with X-ray in the diagnosis of biliary tract pathology. 3. Finding crystals in the bile is not pathonomonic of stones, but is evidence of pathology in the biliary tract.