Biliary Tree In Patients Research Articles

Comparative study of Endoscopic Retrograde Cholangiopancreatography Findings versus Magnetic Resonance Cholangiopancreatography in detection of lesions of the biliary tree in patients with common bile duct dilatation

Comparative study of Endoscopic Retrograde Cholangiopancreatography Findings versus Magnetic Resonance Cholangiopancreatography in detection of lesions of the biliary tree in patients with common bile duct dilatation

Antegrade Therapy for Management of Choledocholithiasis through Endoscopic Ultrasound-Guided Hepaticogastrostomy in a Patient with Surgically Altered Gastrointestinal Anatomy

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a technique used to access the biliary tree in patients with surgically altered anatomy. Additionally, development of EUS-HG fistula permits intraductal therapy, thereby preventing patients from requiring surgery or percutaneous transhepatic biliary drainage (PTBD), thus decreasing morbidity. This clinical vignette describes an 83-year-old man with a history of gangrenous cholecystitis requiring cholecystectomy, partial gastrectomy, and Roux-en-Y gastrojejunostomy who presented to an outside hospital with abdominal pain and fever and found to have cholangitis and choledocholithiasis. He underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures at an outside hospital which were unsuccessful due to an inaccessible major papilla in the setting of the patient's surgically altered anatomy. On arrival to Wake Forest, the patient underwent EUS-HG with successful biliary drainage and resolution of cholangitis. He returned for ERCP three months later with balloon sphincteroplasty, cholangioscopy, and electrohydraulic lithotripsy (EHL) performed through the existing metal stent (hepaticogastrostomy), resulting in stone fragmentation and antegrade removal with balloon sweeps. Repeat cholangioscopy post-EHL and balloon sweeps showed complete duct clearance with no residual stones. The hepaticogastrostomy stent was subsequently removed, and the patient recovered without any complications.

OC-075 Outcomes of Percutaneous Transhepatic Cholangiography for the Palliative Relief of Malignant Jaundice in England Between 2001 and 2014

Introduction Percutaneous transcutaneous cholangiography (PTC) is widely used to relieve malignant obstructive jaundice, especially when endoscopic retrograde cholangiopancreatography (ERCP) has failed. Decompression of the biliary tree in patients who are not suitable for surgical resection may improve quality of life and facilitate palliative chemotherapy. Methods Using Hospital Episode Statistics (HES), patients with cancer of the pancreas, biliary tree, gallbladder, small intestine and liver that underwent PTC were identified. Patients who underwent curative resection post PTC were excluded. Mortality, complication rates, readmissions and variation in outcomes between healthcare providers were examined. Associations between age, sex, comorbidity, cancer type and mortality were examined using multivariate regression analysis. Results Between April 2001 and March 2014, 16,363 subjects were identified (50.2% male and mean age 73). Pancreatic cancer was the most common site at 58% and 61.1% of patients had undergone a previous ERCP. In-hospital and 30 day mortality was 15.3% (CI14.8–15.9%) and 23.1% (CI 22.5–23.8%) respectively and median survival was 92 days (IQR 33–244). There was no reduction in mortality over the study period. The percentage of patients receiving chemotherapy after their PTC was 40.7% in those aged under 60 but fell to 2.5% in those aged over 80. Emergency readmission rate was 20.6%. 35.7% of patients suffered a serious complication after their procedure, the most common being infective (16.2%), stent blockage or displacement (6.2%) and acute kidney injury (4.7%). 30 day mortality was associated with increasing age (80+ years, OR 2.91 (95% CI 2.53–3.33) p Conclusion In subjects undergoing PTC for the palliative relief of malignant jaundice, 30 day mortality is 23.1%, major complications occur in 35.7% and readmission occurs in 20.6%. Mortality is highest in older males with increasing co-morbidity and in trusts performing low volumes of procedures. Careful multidisciplinary selection of patients who will benefit from PTC for relief of significant symptoms from jaundice or as a bridge to chemotherapy is clearly merited. Disclosure of Interest None Declared

EUS hepaticogastrostomy for bilioenteric anastomotic strictures: a permanent access for repeated ambulatory dilations? Results from a pilot study.

Background and study aims: Postsurgical benign bilioenteric anastomotic strictures are a major adverse event of biliary surgery and endoscopic treatment, including endoscopic retrograde cholangiopancreatography (ERCP), is challenging in this setting. We present an innovative approach to treating this complication. Patients and methods: Patients underwent endoscopic ultrasound (EUS)-hepaticogastrostomy (HG) to treat nonmalignant biliary obstructions. A first endoscopy was performed to create the hepaticogastrostomy and to drain the biliary tree. The second step had a therapeutic purpose: antegrade dilation of the anastomosis. Results: Four men and three women with benign bilioenteric anastomotic strictures were included. Patients presented with jaundice or recurrent cholangitis. A fully covered HG stent was successfully deployed during the first endoscopy. During the second step, repeat antegrade dilation was performed through the HG in four cases (1 – 4 dilations) followed by double pigtail stenting in three cases. In three other patients, the stenosis was not crossable and a double pigtail stent was placed to maintain biliary drainage. All patients had symptom relief at the end of follow-up (45 weeks, range 33 – 64). Conclusions: Dilation of anastomotic stenosis through a hepaticogastrostomy is feasible and may provide permanent biliary drainage or recurrent access to the biliary tree in patients with altered anatomy. Double pigtail stents might prevent migration.

Efficacy of gadoxetic acid-enhanced magnetic resonance cholangiography compared with T2-weighted magnetic resonance cholangiography in patients with liver cirrhosis

BackgroundGadoxetic acid is one of the hepatobiliary-specific agents and so can be used for contrast-enhanced magnetic resonance cholangiography (CE-MRC). The aim of our study was to compare the performance of CE-MRC with that of T2-weighted magnetic resonance cholangiography (T2W-MRC), and also to ascertain the effectiveness of both modalities combined for visualizing anatomic structures of the biliary tree in patients with liver cirrhosis. MethodsFifty-six patients underwent CE-MRC and T2W-MRC imaging. In the CE-MRC studies, hepatobiliary phase images were acquired 20 minutes after contrast injection. Two radiologists first evaluated the T2W-MRC and CE-MRC images separately in random order, and then they reviewed both images together 8 weeks later. The readers graded the quality of visualization of each biliary duct and the entire biliary tree (overall rating) using a five-point scale. Images with a grade of 3 or 4 were considered to provide sufficient visualization for clinical application, and those with a grade of 2 or less were considered to provide insufficient visualization. Laboratory data, Child–Pugh classification, and model for end-stage liver disease score were also recorded. ResultsThe overall rating of T2W-MRC was significantly higher than that of CE-MRC (p < 0.001), although combined T2W/CE-MRC provided better visualization of biliary segments than T2W-MRC alone (p = 0.025). There were no significant differences between liver function and the overall rating of CE-MRC. ConclusionCE-MRC is not superior to conventional T2W-MRC with respect to biliary visualization in patients with liver cirrhosis. However, a combination of T2W-MRC and CE-MRC provides significantly better visualization of biliary structures than T2W-MRC alone.

Su1400 PerOral Cholangioscopy in PSC and Non PSC Patients With Suspected Cholangiocarcinoma

PSC is a chronic inflammatory condition of the bile ducts which puts patients at increased risk of developing cholangiocarcinoma. Peroral cholangioscopy performed during ERCP allows clinicians to directly visualize the biliary tree in patients with PSC and/or suspected cholangiocarcinoma and may help identify sites for tissue acquisition for the detection of cholangiocarcinoma. We evaluated our experience using cholangioscopy in patients with PSC and/or suspected cholangiocarcinoma as a means to target sites for tissue acquisition and to detect malignancy.

Contrast Enhanced Ultrasound Cholangiography via T-Tube Following Liver Transplantation

The objective was to evaluate contrast enhanced ultrasound (CEUS) based cholangiography compared to conventional radiography as a reference method in patients after liver transplantation. Contrast agents were administered through T-tubes, which were placed during the operation. Twelve patients with side-to-side choledochocholedochostomy and standardized intraoperative T-tube placement were investigated on the 5th postoperative day (POD 5) with both techniques. All images were digitally acquired and assessed in consensus by two investigators regarding complete anatomic visualization, depiction of pathology (e.g. delayed contrast outflow, leakage) and general image quality. CEUS cholangiography showed comparable results in the detection of biliary pathology and overall image quality. Regarding the visualization of the extrahepatic bile duct CEUS produced limited results in 6 patients. In conclusion, CEUS cholangiography represents a fast and easy accessible technique for the depiction of the biliary tree in patients after liver transplantation.

Laparoscopic Transgastric Endoscopy after Roux-en-Y Gastric Bypass: Case Series and Review of the Literature

Endoscopic access to the gastric remnant and pancreatobiliary tree is technically difficult after Roux-en-Y gastric bypass even when facilitated by the use of specialized techniques such as balloon enteroscopy and the use of overtubes. Furthermore, such techniques are not universally available at all medical centers. We describe a case series of 13 patients with a history of Roux-en-Y gastric bypass for the treatment of morbid obesity who underwent laparoscopic transgastric endoscopy through the gastric remnant to access the duodenum or biliary tree. Charts of these patients were reviewed for demographics, indications for procedure, length of stay, morbidity, and mortality. Four of the patients had failed prior attempts to access the excluded anatomy through traditional transoral endoscopy. Two patients underwent transgastric endoscopy for evaluation of gastrointestinal bleeding. Of the 11 patients for whom endoscopic retrograde cholangiopancreatography was planned, all underwent successful biliary cannulation and sphincterotomy. There were no conversions to an open procedure or complications during the follow-up period. Laparoscopic transgastric endoscopy is a safe and reliable method to access the excluded stomach and biliary tree in patients with a history of Roux-en-Y gastric bypass.

Role of Intraoperative Cholangiography in Patients Whose Biliary Tree Was Evaluated Preoperatively by Magnetic Resonance Cholangiopancreatography

Routine performance of intraoperative cholangiography (IOC) during cholecystectomy is controversial. The aim of this study was to evaluate the role of IOC during cholecystectomy in addition to preoperative magnetic resonance cholangiopancreatography (MRCP) in our institution over a 12-year period. A total of 425 consecutive patients who underwent IOC during cholecystectomy were included in this study. MRCP was performed preoperatively for bile duct evaluation in all patients. When common bile duct (CBD) stones were detected, they were removed endoscopically before the operation. We estimated the results of IOC in terms of the success rate, the detection rate of anatomic abnormality of the biliary system, and the incidence of residual CBD stones. MRCP preoperatively identified 6 (1.4 %) patients with abnormal biliary systems and 56 with CBD stones, which were endoscopically removed. The success rate of IOC was 93.8 % (399/425). Abnormalities of the biliary system were detected in 12 patients (12/399, 3.0 %) and CBD stones in 8 (8/399, 2.0 %). Of the eight patients with stones, seven had been examined by endoscopy preoperatively and found to have CBD stones. The detection rate of bile duct stones in patients with preoperative endoscopic removal of CBD stones (7/56, 12.5 %) was significantly higher than those with CBD stones first detected during IOC (1/365, 0.3 %) (p < 0.01). Moreover, no residual CBD stones were detected in patients who were operated on within fewer than 12 days from endoscopic treatment to the operation. IOC is indicated even after preoperative sphincterotomy for CBD stones. In our study, it resulted in a 12.5 % incidence of persistent stones after sphincterotomy. IOC plays an additional role in detecting CBD stones and in revealing abnormalities of the biliary tree in patients whose biliary tree was preoperatively evaluated by MRCP.

Percutaneous ultrasound-guided drainage of the biliary tree in palliative treatment of mechanical jaundice: 17 years of experience.

IntroductionAdvanced malignant tumours involving the head of the pancreas, gallbladder or extrahepatic bile ducts usually lead to the development of cholestasis. In such cases improvement of the quality of life of patients can be achieved with the decompression of jaundice. Endoscopic implantation of self-expanding or (seldom) rigid plastic stents into the biliary tree constitutes the most common technique allowing for restoration of bile duct patency. In some patients however the use of such a procedure is technically impossible. In this particular group percutaneous drainage of the biliary tree can constitute the only method of management.AimPresentation of our experience with the use of percutaneous ultrasound-guided drainage of the biliary tree in patients with mechanical jaundice resulting from malignant tumours.Material and methodsThere were 852 patients with mechanical jaundice resulting from malignant neoplasms treated in the 2nd Chair of Surgery of Jagiellonian University Medical College from January 1994 to December 2010. In 199 of them jaundice was decompressed by means of open – radical or palliative – surgical operations. In 539 patients endoscopic treatment was implemented while in 114 of them percutaneous ultrasound-guided drainage was performed.ResultsIn 5 patients percutaneous drainage was introduced to prepare them for radical surgical treatment, while in the remaining 109 it constituted the definitive way of management. The average hospitalization time for women was 6.5 days (range: 1-22 days) and proved to be twice as short as in men – 12.2 days (range: 1-38 days). The duration of percutaneous drainage prior to surgical treatment averaged 7.2 days (range: 6-10 days). Mean volume of the bile drained during the first day was 370 ml (range: 10-1300 ml), increased to 450 ml (range: 100-1150 ml) during the second day and reached 780 ml (range: 80-1600 ml) during the third day. Mean bilirubin level before the drainage was 320-23 µmol/l (range: 658-130.7 µmol/l) and decreased by half before discharge or before the operation, reaching on average 181.87 µmol/l (range: 14.5-343 µmol/l).ConclusionsComplications of the percutaneous ultrasound-guided technique were found sporadically and resulted from leakage of the bile into the peritoneum.

The detection of cysto-biliary communications during surgery for liver hydatid cysts: let's speak the unspoken

We read with great interest the article by Kayaalp et al. (1), whose work identified biliary orifices using a bile test and described the use of suturing cysto-biliary communications to reduce postoperative biliary complications significantly following hydatid liver surgery. We would like to express our opinion that testing using the injection of normal saline into the biliary system has several disadvantages based on three important concerns. First, normal saline is colorless, and in some cases, small or hidden cysto-biliary communications may not be detected. Why did the authors not use a colored agent, such as methylene blue? Second, small daughter cysts and minor fragments of cysts in the biliary tree may not be detected by injecting normal saline. How did the authors evaluate the whole biliary tree in patients with cysto-biliary communications? Third, in some cases, especially for deep cysts with multiple connections, the whole cavity may not be observable by the naked eye using a colorless agent. How did the authors evaluate the cyst cavities in these patients? During routine surgical practice, we prefer injecting water-soluble contrast media and using cholangiography in patients with suspected cysto-biliary communications (Figure 1). If we detect leaks using cholangiography, we can inject methylene blue into the biliary system to find hidden orifices (2). There are certain advantages to using this technique. First, the surgeon can see the location and the diameter of the cysto-biliary communications and understand the severity of the problem. Second, using cholangiography, small daughter cysts or minor fragments of endocysts in the biliary tree can be detected. Third, hidden biliary-thoracic communications can be visualized. Fourth, the use of cholangiography may prevent the complete suture capture and occlusion of biliary branches when suturing cysto-biliary communications.

An Alternative Route into the Biliary Tree Following Gastric Bypass Surgery

We present a novel case with a combined procedure of laparoscopic cholecystectomy and laparoscopic-facilitated endoscopic retrograde cholangio-pancreatography (ERCP) in a patient who had previously undergone laparoscopic Roux-en-Y gastric bypass surgery 2 years earlier. At a follow-up bariatric clinic, 2 years postobesity surgery, this 50-year-old patient complained of right upper quadrant pain and nausea. Ultrasonography and magnetic resonance cholangio-pancreatography demonstrated multiple stones within the gallbladder and in the common bile duct (CBD). A planned joint procedure with the gastroenterologists was performed. Access to the abdomen was obtained via a subumbilical port inserted under direct vision. Pneumoperitoneum was obtained and four further ports were placed. The cystic duct was identified and cannulated, and an on-table cholangiogram was performed, which confirmed the presence of multiple stones in the distal CBD. However, only one stone was amenable to extraction via a Fogarty balloon trawl. As the CBD was too narrow for choledochotomy and CBD exploration, it was decided to proceed to laparoscopic gastrostomy and transgastric ERCP. The gastrostomy was fashioned in the remnant stomach and secured with a purse string suture. A 15-mm port was then inserted into the left upper quadrant and a side-viewing endoscope was introduced through this port into the gastrostomy. The duodenal papilla was identified and cannulated, and a cholangiogram reconfirmed stones in the CBD. A sphincterotomy was performed, followed by a balloon trawl and extraction of the gallstones. Completion cholangiogram demonstrated a clear biliary tree. Single layer closure of the gastrostomy and laparoscopic cholecystectomy was then undertaken. This patient made an uneventful recovery and was discharged home 2 days postprocedure. We suggest that this is a useful technique for the retrieval of stones in the biliary tree in patients who have had previous Roux-en-Y gastric bypass surgery. No competing financial interests exist. Runtime of video: 6 mins 52 secs

Endoscopic Retrograde Cholangiopancreatography with Single-Balloon Enteroscopy Is Feasible in Patients with a Prior Roux-en-Y Anastomosis

The purpose of this study is to describe the feasibility of using single-balloon enteroscopy (SBE) to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who had a prior Roux-en-Y (RY) anastomosis. This case series describes four patients, one with RY gastric bypass, two with RY due to bile duct injury, and one with RY after liver transplantation, who underwent ERCP with SBE. Cholangiography was successful in three of the four patients. In the procedure that was not successful, the enteroenterostomy site could not be located. The successful procedures ranged from 65-91 min in duration. Medication doses were higher than with typical ERCPs. No procedural complications occurred. SBE for ERCP is a feasible option for endoscopic access to the biliary tree in patients with prior RY anastomoses. Limitations of this technique include the time requirement, delay in identification of the enteroenterostomy site, potential learning curve, and immature technology lacking accessories.

The Selective Use of Magnetic Resonance Cholangiopancreatography in the Imaging of the Axial Biliary Tree in Patients with Acute Gallstone Pancreatitis

Background: Magnetic resonance cholangiopancreatography (MRCP) is an emerging modality in the management of acute gallstone pancreatitis (AGP). The aim of this study was to assess the impact following the introduction of MRCP in the management of AGP in a tertiary referral unit. Methods: Patients presenting with AGP from January 2002 to December 2004 were reviewed to assess the impact of the introduction of MRCP in June 2003. The indication for MRCP was suspected common bile duct (CBD) stones in the absence of biliary sepsis. Definitive treatment for AGP was laparoscopic cholecystectomy, with endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy reserved for patients unfit for cholecystectomy and those with biliary sepsis. Results: 249 patients were identified of whom 36 (14.5%) underwent ERCP and sphincterotomy as definitive treatment. 96 patients with a non-dilated CBD and normal or resolving liver function tests proceeded to laparosocopic cholecystectomy and intraoperative cholangiogram (IOC), 8 (8.5%) of whom had CBD stones intraoperatively. Eleven patients underwent cholecystectomy during pancreatic necrosectomy. Of those undergoing preoperative diagnostic biliary tract imaging, ERCP was undertaken in 57 patients and MRCP in 49 patients. There was no significant difference in serum bilirubin levels [ERCP 43 mmol/l (18–204) vs. MRCP 39 mmol/l (24–180), p = NS] or the proportion of patients with CBD stones [ERCP 10 (17.5%) vs. MRCP 7 (14.2%), p = NS] between the two groups. Patients who underwent MRCP had a shorter median hospital stay [MRCP 5 days (range: 3–14) vs. ERCP 9 days (range: 4–20), p < 0.01] and higher rate of cholecystectomy during the index admission (MRCP 83.3% vs. ERCP 67.2%, p < 0.05). There was a high degree of correlation between preoperative MRCP results and findings of subsequent IOC or therapeutic ERCP (area under ROC curve: 0.94). Conclusions: MRCP is an accurate modality for imaging the axial biliary tree in patients with AGP. Selective use of MRCP reduces the need for ERCP and results in shorter hospital Stay.

A child with chromosome 22q11.2 deletion syndrome and a bilobed gallbladder

We present an 11-year-old girl with a chromosome 22q11.2 microdeletion, velocardiofacial syndrome (VCFS), and a bilobed gallbladder as an incidental finding on abdominal sonography. The finding was confirmed by magnetic resonance cholangiopancreatography (MRCP). This is the first report of a gallbladder anomaly associated with a chromosome 22q11.2 deletion and the second report of a biliary tract anomaly associated with a mutation in the chromosome 22q11 region. We suggest that close attention be paid to the anatomy of the biliary tree in patients with mutations in the chromosome 22q11 region. Further study is warranted to determine the range and prevalence of biliary tract anomalies in this population.

Laparoscopic transgastric endoscopy after Roux-en- Y gastric bypass

Background Access and endoscopic evaluation of the bypassed stomach is difficult after laparoscopic Roux-en- Y gastric bypass. We propose a minimally invasive technique to access the bypassed stomach after Roux-en- Y gastric bypass for endoscopic diagnosis and treatment. Methods First, we established carbon dioxide pneumoperitoneum to a pressure of 12–15 mm Hg. Next, 12-mm umbilical, 5-mm right upper quadrant, 5-mm left lower quadrant, and 15-mm left upper quadrant trocars were placed. A purse-string suture was placed on the anterior wall of the stomach. A gastrotomy was made using ultrasonic shears and the 15-mm trocar was placed into the stomach. The endoscope was then inserted through the 15-mm trocar, and the pneumoperitoneum was decreased to 10 mm Hg. Once the evaluation was complete, the gastrotomy was closed with a running suture or linear stapler. Results Ten patients at our institution have undergone laparoscopic transgastric endoscopy. Five patients had biliary pathologic findings. Four of these patients underwent successful endoscopic retrograde cholangiopancreatography and papillotomy; the procedure in the fifth patient was unsuccessful because stone impaction at the ampulla. Three patients were evaluated for gastrointestinal bleeding. One was diagnosed with a duodenal gastrointestinal stromal tumor, one with a bleeding duodenal ulcer, requiring surgical exploration; and the third had negative endoscopy findings. Two patients evaluated for chronic abdominal pain had negative endoscopy findings. No complications developed. Conclusions Laparoscopic transgastric endoscopy is a safe and minimally invasive approach for the evaluation of the gastric remnant, duodenum, and biliary tree in patients who have undergone Roux-en- Y gastric bypass.

Use of self-expandable metallic stents in benign GI diseases

The self-expandable metallic stent is of proven benefit in patients with malignant disease; however, its use in patients with benign disease is not well established. There are few data available regarding long-term complications and outcomes with use of self-expandable metallic stents in benign disease and virtually none regarding attempted removal once the acute problem is resolved. Thirteen patients who had a self-expandable metallic stent placed for benign GI disorders were included in a retrospective analysis. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. Thirteen patients (7 women, 6 men; mean age 67 years, range 34-84 years) had one or more self-expandable metallic stents placed for benign disease and were followed for a mean of 3.4 years (3 weeks to 10 years). Of the 13 patients, 8 had esophageal stents, 4 biliary stents, and 1 had dual stents placed in the pancreaticobiliary tree. Complications developed in 8 (62%) patients; 4 (31%) ultimately died, either from the primary disease process (3) or from stent-related complications (1). Self-expandable metallic stent placement is effective treatment for benign esophageal leaks, providing the stent can be removed. It also may be used in either the esophagus or biliary tree in patients who are poor candidates for surgery and short expected survival. However, a self-expandable metallic stent should not be placed in a patient with a benign GI disorder who has a significant life expectancy and is a good candidate for surgery.

HIV-associated biliary tract disease

Disorders of the biliary tree in patients with human immunodeficiency virus are well recognized. In patients with acquired immunodeficiency syndrome (AIDS), bile duct disease, termed AIDS Cholangiopathy, is often infectious in etiology. These disorders typically manifest as abnormal liver tests, primarily alkaline phosphatase, and right upper quadrant pain. Abdominal imaging may suggest the diagnosis when biliary dilatation is observed. Recognition of these disorders is important as endoscopic retrograde cholangiopancreatography may be both diagnostic and therapeutic.

Magnetic resonance cholangiography in patients with biliary disease: its role in primary sclerosing cholangitis

Background/Aim: Magnetic resonance cholangiography (MRC) is a non-invasive diagnostic procedure whose role in the management of patients with primary sclerosing cholangitis (PSC) is unclear. The aim of this study was to determine the usefulness of MRC in the evaluation of the biliary tree in patients with suspected biliary disease, and in particular, PSC. Methods: MRC and invasive cholangiography (ERCP or PTC) were both performed in 73 patients, (33 male, 40 female, mean age 56 years) with clinical and/or biochemical evidence of cholestasis. Images were interpreted by two radiologists unaware of the results of other studies. Results: Forty-two patients (58%) had benign biliary disease, including 23 patients (32%) with PSC; 9 patients (12%) had malignant biliary disease; and 22 patients (30%) had a normal biliary tree. Diagnostic quality images were obtained in 73/73 (100%) of MRC, and in 70/73 (96%) of invasive cholangiography (68 ERCP's, 2 PTC's) procedures. Using ERCP/PTC findings as the reference standard, MRC had an accuracy greater than 90% in the diagnosis of normal bile ducts, biliary dilatation, biliary obstruction, bile duct stones, and PSC. Using the final diagnosis, MRC had an overall diagnostic accuracy of 90% in the detection of biliary disease compared to 97% for invasive cholangiography. Additional diagnostic/therapeutic interventions were performed during ERCP in 73% of patients with PSC and in 43% of patients without PSC ( p=0.02). Conclusions: MRC has excellent diagnostic accuracy in the presence of biliary disease. Because of its noninvasive nature, MRC may have advantages over invasive cholangiography when diagnosis is the major goal of the procedure.

Cryptosporidium parvum induces apoptosis in biliary epithelia by a Fas/Fas ligand-dependent mechanism.

Although the clinical features of sclerosing cholangitis from opportunistic infections of the biliary tree in patients with acquired immunodeficiency syndrome (AIDS) are well known, the mechanisms by which associated pathogens, such as Cryptosporidium parvum, cause disease are obscure. Using an in vitro model of biliary cryptosporidiosis, we observed that C. parvum induces apoptosis in cultured human biliary epithelia. Both caspase protease inhibitors and neutralizing antibodies to either Fas receptor (Fas) and Fas ligand (FasL) inhibited this process; neutralizing antibodies to other apoptotic cytokines [interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), and transforming growth factor-beta (TGF-beta)] had no effect. C. parvum stimulated FasL membrane surface translocation, increased both FasL and Fas protein expression in infected biliary epithelia, and induced a marked increase of soluble FasL (but not IL-1beta, TNF-alpha, and TGF-beta) in supernatants from infected cells. When a coculture model is used in which infected and uninfected cell populations were physically separated by a semipermeable membrane, both uninfected biliary epithelia and uninfected Fas-sensitive Jurkat cells (but not a Fas-resistant Jurkat cell line) underwent apoptosis when cocultured with infected biliary epithelia. Moreover, both a neutralizing antibody to FasL and a metalloprotease inhibitor blocked the apoptosis in uninfected cocultured cells. Activation of caspase activity was also observed in uninfected cocultured biliary epithelia. The data suggest that C. parvum induces apoptosis in biliary epithelia by a Fas/FasL-dependent mechanism involving both autocrine and paracrine pathways. These observations may be relevant to both the pathogenesis and therapy of the cholangitis seen in AIDS patients with biliary cryptosporidiosis.