Extrahepatic Bile Duct Dilatation Research Articles

Chronic Extrahepatic Bile Duct Dilatation: Sonographic Screening in the Patients with Opioid Addiction

ObjectiveOne of the best known side effects of using opium is spasm of the sphincter of Oddi, which may increase the diameter of the extrahepatic bile ducts. Ultrasound is the first imaging modality used for evaluating the biliary system because it is commonly available and noninvasive. The principal objective of this study was to measure the common bile duct (CBD) diameter via ultrasonography in opium addicts and to evaluate the relation between the CBD diameter and the period of addiction.Materials and MethodsThis research was an analytical-cross sectional study that was done on 110 opium addicts that were admitted to a drug treatment center. The diameter of the CBD in these cases was measured by ultrasonography and the results were analyzed with other factors like age, the period of addiction and the laboratory findings.ResultsAccording to the findings, there is a significant increase in the range of the CBD diameter in comparison with normal bile ducts. Also, the mean diameter of the CBD in the different age groups showed a significant difference (p < 0.0001) and there was a significant relation between the CBD diameter and the period of addiction (p < 0.001, r = 0.74); so, with the increased length of the addiction period, the mean CBD diameter increases.ConclusionOpium addiction is one of the factors that causes extrahepatic bile duct dilatation, so in these cases, if no obstructing lesion was found on ultrasound examination and the serum bilirobine and alkaline phosphatase levels are normal, then further evaluation is not needed.

Acute Pancreatitis Secondary to Migrated Gastrostomy Tube

The aim of our study is to evaluate the pattern of acute pancreatitis due to the migration of Gastrostomy tube (GT). There were four cases of acute pancreatitis with a possible relation to migration of feeding tube. The diagnosis of acute pancreatitis was confirmed by significant elevation of serum Amylase and Lipase and CT scan findings of peri-pancreatic inflammatory changes. Clinical presentation, laboratory values, radiological findings and outcome of these patients were recorded. Initial symptoms were vomiting in two cases and abdominal pain and vomiting in another two cases. All four cases had a migrated GT balloon through the pylorus confirmed clinically or radiographically. Amylase and Lipase values were more than 10 times normal and values declined significantly within 24 hours of repositioning the feeding tube by pulling the balloon back into the stomach. Complete resolution of symptoms occurred within 48 hours after repositioning of the GT and intravenous hydration. Liver chemistries were within normal limits and there was no CT or sonographic evidence of intra or extra hepatic bile duct dilatation. Pancreas related complications were not observed in the four patients. However, two cases were complicated by pneumonia and urinary tract infection. All gastrostomy tubes were balloon type. In all cases, the initial physical exam done by the gastroenterologist revealed a migrated tube. Migration of gastrostomy tube through the pyloric channel may lead to acute pancreatitis. In this series, all cases were mild and responded to intravenous hydration and relocation of the balloon out of the duodenum and into the stomach. The cause for the development of acute pancreatitis can be the obstruction of ampulla of Vater or pancreatic duct by direct pressure of the migrated balloon. These cases could have been prevented by proper awareness of health care professionals or caretakers of physical signs of migrated feeding tube.

Agenesis of the Gallbladder With Hypoplastic Cystic Duct Diagnosed at Laparoscopy

An 86-year-old man was admitted to our department with complaints of intermittent upper abdominal pain. Ultrasonography of the abdomen showed dilated extrahepatic bile ducts containing stones; however, the gallbladder was not clearly identified. Magnetic resonance cholangiopancreatography showed dilated extrahepatic ducts and choledocholithiasis without gallbladder visualization. The stone extraction was performed with endoscopic sphincterotomy. Three-dimensional images using spiral-computed tomography after intravenous-infusion cholangiography clearly demonstrated an obstruction of the cystic duct. The patient was scheduled for laparoscopic cholecystectomy. At laparoscopy, the gallbladder fossa was not identified on the undersurface of the liver. Despite a thorough examination of the intrahepatic (left-sided within the lesser omentum), retroperitoneal, retrohepatic (within the falciform ligament), retroduodenal, and retropancreatic areas using laparoscopic ultrasonography, the gallbladder was not found. After careful dissection of the hepatoduodenal ligament, the dilated extrahepatic bile duct and a 1-cm length of hypoplastic cystic duct were found. Gallbladder agenesis is usually accompanied by the lack of the cystic duct. The present case is the third report of gallbladder agenesis with a patent or hypoplastic cystic duct.

Biliary Carcinoma Risk in Patients with Pancreaticobiliary Maljunction and the Degree of Extrahepatic Bile Duct Dilatation

Background and Aim: In patients with pancreaticobiliary maljunction (PBM), pancreatic juice frequently refluxes into the bile duct. This results in a high risk of biliary carcinoma. No consensus has been reached on whether preventive resection of the extrahepatic bile duct is necessary in PBM cases without dilatation of the extrahepatic duct. The aim of this study is to examine the biliary complications of patients with PBM in relation to the degree of extrahepatic bile duct dilatation and thus to determine appropriate management. Patients and Methods: We have treated 98 patients (21 males and 77 females, average = 48.0) with PBM. The PBM cases could be divided into 5 groups according to the maximum diameter of the extrahepatic bile duct:≤10, 11-15, 16-20, 21-30, ≥31mm. The clinicopathological findings of biliary carcinomas associated with PBM were examined and compared with 232 cases of gallbladder carcinoma and 159 cases of bile duct carcinoma that were not associated with PBM. Results: Gallbladder carcinoma occurred in 36 of 65 patients (55%) with PBM whose maximum diameter of the extrahepatic bile duct was ≤30 mm, but no gall bladder carcinoma occurred in patients with PBM whose maximum diameter of the extrahepatic bile duct was ≥31 mm. Bile duct carcinoma occurred in 6 of 52 patients (12%) with PBM whose maximum diameter of the extrahepatic bile duct was ≥21 mm, but no bile duct carcinoma occurred in patient with PBM whose maximum diameter of extrahepatic bile duct was ≤20 mm. The age at diagnosis of the patients with gall bladder (58.9 ± 8.8 vs. 69.4 ± 8.7 years old, p < 0.01) or bile duct carcinoma (54.8 ± 14.3 vs. 68.8 ± 9.1 years old, p < 0.01) associated with PBM was significantly younger than those without PBM. Gallstones were rarely detected in patients with gallbladder carcinoma associated with PBM (8% vs. 62%, p < 0.01). There were no significant differences between cases of gallbladder carcinoma associated with and without PBM in the location and histology, incidence of multiple biliary carcinoma. Multiple biliary carcinomas frequently occurred in the patients with bile duct carcinoma associated with PBM (50% vs. 4%, p < 0.01). Conclusion: PBM with an extrahepatic bile duct diameter ≤30 mm is associated with a high risk of gallbladder carcinoma. Furthermore, PBM with an extrahepatic bile duct diameter ≥21 mm is associated with a high risk of bile duct carcinoma. The treatment of choices for PBM with biliary dilatation is excision of extrahepatic bile duct and gallbladder with Roux-en-Y reconstruction of the biliary tree. However, given the present study, only cholecystectomy should be recommended as prophylactic treatment for patients with PBM without biliary dilatation.

Liver resection as the definitive treatment for unilateral non-oriental primary intrahepatic lithiasis

Background The current study sought to evaluate the results of liver resection as the treatment for unilateral non-oriental primary intrahepatic lithiasis (PHIL). Methods Twenty-seven symptomatic patients (mean age 42 years) were submitted to liver resection; the indications were parenchymal fibrosis/atrophy in 22 and biliary stenosis in 5. Resection was associated with a Roux-en-Y hepaticojejunostomy in patients with a significant degree of dilation of the extrahepatic biliary duct. Results There was no operative mortality and the morbidity rate was 7.4% (2 patients with biliary fistula). After a median follow-up of 41.2 months, the overall rate of good results was 92.6%. All patients submitted to liver resection alone presented good late results, while 80% of those with associated hepaticojejunostomy did not have complications ( P = .12). Late complications were observed in 2 patients (7.4%): 1 with a liver abscess and 1 with cholangitis and recurrent stones. There was no mortality during long-term follow-up. Conclusions Liver resection showed low incidence of complications and good long-term results. None of the patients with unilateral disease without associated extrahepatic bile duct dilation presented complications and they were considered cured. We believe that resection indications should be expanded and the procedure should be indicated as routine in patients with unilateral PHIL even in the absence of parenchymal fibrosis/atrophy or biliary stenosis.

Congenital Dilatation of Extrahepatic Bile Ducts in Children. Experience in the Central Hospital of Hue, Vietnam

The authors present a study of a series of cases in children with congenital dilatation of the extrahepatic bile ducts (CDEBD). Between November 1998 and October 2002, 38 children aged between 50 days and 15 years suffering from CDEBD, admitted to the Central Hospital in Hue, Vietnam, were treated surgically with a minimum follow-up of one year. Diagnosis was based only on ultrasonography which was 100% accurate. According to Miyano's classification, 26 cases presented as cystic dilatation of the main bile duct (MBD) associated with dilatation of the intrahepatic bile ducts, while in the other 12 cases the dilatation of the MBD was of the fusiform type. The surgical treatment of choice was extensive excision of the dilatated extrahepatic bile ducts and biliary drainage according to the Roux-en-Y method in 36/38 patients. The other two patients underwent surgery for internal biliary drainage without removing the cysts. During follow-up we observed one case of pancreatitis out of the 36 patients who underwent excision of the dilatated extrahepatic bile ducts, while the two patients who had internal biliary drainage without removal of the cysts suffered from numerous attacks of cholangitis. The reflux of bile in the dilated biliary tree plays an important role in the etiopathogenesis of CDEBD. Excision of the extrahepatic bile ducts and internal biliary drainage by Roux-en-Y has proved a satisfactory surgical method.

Extrahepatische Cholestase unter Therapie mit Zolmitriptan (Asco-Top)

Because of recurrent abdominal pain, jaundice and elevated liver function tests, a sixty-two-year old man had been referred to hospital several times within the preceding six months. By means of ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonant cholangiopancreatography, dilated extrahepatic bile ducts were diagnosed. Stones and a tumorous process were excluded. ERCP showed hypermotility of the upper gastrointestinal tract. Quantitative hepatobiliary scintigraphy demonstrated retention of activity in the intra- and extrahepatic bile ducts and delayed transit of activity to the duodenum as signs of papillary dysfunction. Drug anamnesis revealed that the patient had started migraine treatment with Zolmitiptan, a 5-HT (1B/1D)-receptor agonist of the second generation, six months before the beginning of the cholestasia syndrome. Because of the known increase in amplitudes of oesophageal motor waves and of lower oesophageal sphincter tone by Sumatriptan, a 5-HT (1B/1D)-receptor agonist of the first generation, Zolmitriptan treatment was stopped. Thereupon, laboratory findings normalised and the patient has been feeling well for more than one year. Serotonin is an important monamine neurotransmitter that acts both in the CNS and in the gastrointestinal tract on identical receptors and is transported by the same systems. Thus it is not surprising that therapeutic measures which influence the serotoninergic system in the CNS are also effective in the enteric nervous.

MRI combined with MR cholangiopancreatography versus helical CT in the evaluation of patients with suspected periampullary tumors: a prospective comparative study

To establish the diagnostic accuracy of MRI including MR cholangiopancreatography (MRCP) compared with helical CT in the differentiation of malignant and benign lesions in the periampullary region. Fifty-one patients (27 M, 24 F, mean age 66 years, range 39-86 years) with obstructive jaundice and sonographic evidence of intra- and extrahepatic bile duct dilatation (n=31) or suspicion of periampullary tumor, based on previously performed ultrasound and/or CT examination (n=20), were studied. MRI with MRCP and helical CT were reviewed blindly under standardized conditions. Lesion status (differentiation of malignant versus benign) was rated on a 5-point diagnostic confidence scale. Reference standards for comparison were findings at surgery or laparoscopy and/ or the clinical outcome. The predictive value of imaging findings was determined with multivariate logistic regression analysis. The areas under the receiver operating characteristic curve were 0.96 for MRI with MRCP and 0.81 for CT (P <0.05). Multivariate analysis of eight imaging variables at MRI indicated that a stricture with malignant characteristics at MRCP was the best predictor of malignancy. MRI with MRCP was significantly more accurate than CT in differentiating between malignant and benign lesions in patients with suspected periampullary tumors, mainly due to the information obtained on the MRCP images of the biliary and pancreatic duct anatomy.

Biliopancreatic reflux via anomalous pancreaticobiliary junction

A PREVIOUSLY HEALTHY 32-YEAR-OLD WOMAN experienced an attack of mild acute pancreatitis manifested by right upper quadrant abdominal pain and hyperamylasemia (1676 IU/L; normal range, 50 to 240 IU/L). The patient had no history of excessive alcohol intake or jaundice. Conservative treatment improved the acute pancreatitis. Endoscopic retrograde cholangiopancreatography showed a long (11 mm) common channel, a dilated (48 mm) extrahepatic bile duct with gallstones, and nondilated normal pancreatic ducts (Fig 1). These findings represented anomalous pancreaticobiliary junction (APBJ) associated with choledochal cyst (Todani’s type I).1 Drip infusion cholangiography (DIC)-multidetector row computed tomography (MDCT) was performed using Aquilion (Toshiba Medical System, Tokyo, Japan) with four high-resolution detectors. After intravenous injection of a 100-mLdose of iotroxate meglumine (Biliscopin DIC 50; ScheringAG, Berlin, Germany),maximum intensity projection (MIP) images obtained by DIC-MDCT showed a long common channel, a dilated extrahepatic bile duct, and a proximalmain pancreatic duct (of the pancreatic head) (Fig 2). At 30minutes after ingestion of 4 g of dried egg yolk (Molyork; Toho Chemical Co, Osaka, Japan), DIC-MDCT demonstrated the main pancreatic duct more distally (Fig 3). Axial images revealed yolk-induced contraction of the nonopacified gallbladder. This patient underwent excision of the extrahepatic bile duct and gallbladder followed by

Pre-operative ultrasonographic diagnosis of biliary atresia--with reference to the presence or absence of the extrahepatic bile duct.

Our aim was to evaluate the efficacy of ultrasonographic (US) examination in the pre-operative diagnosis of biliary atresia (BA) with special reference to the presence or absence of extrahepatic bile duct. Thirty consecutive neonates and infants aged 8 to 169 days (mean: 62 days) suspected of having biliary atresia were examined pre-operatively in real time B-mode ultrasonography. We used a 5 or 7.5 MHz probe of micro convex type. Patients were fasted and sedatives administered. When the common bile duct was absent, we considered it a positive finding for BA diagnosis; if not, it was considered a negative finding. A definitive diagnosis of BA was confirmed at surgery by gross morphology or intra-operative cholangiography. US findings had a sensitivity of 83% (19 of 23 BA patients), a specificity of 71% (5% of 7 non BA patients) and an accuracy rate of 80%. The positive predictive value was 90% (19 of 21), while the negative predictive value was 56% (5 of 9). There were four false-negative cases. Two were BA cases with patent distal common bile duct, one was BA in which the hepatic artery was determined to be the common bile duct, and the other was a subtype of extrahepatic bile duct dilatation (the so-called, "correctable type"). We employed US criteria for visualization of the extrahepatic bile duct for pre-operative diagnosis of BA. US examination referring to the presence or absence of the extrahepatic bile duct is an effective and useful method for clinical survey.

Giant Brunner's gland hamartoma

A 26-year-old woman with a 2-year history of postprandial abdominal pain, weight loss, and fatigue presented with pruritis and jaundice. Laboratory test results were as follows: hemoglobin, 5.1 g/dL (normal: 11.5-16.5 g/dL); total bilirubin, 31 μmol/L (5-20 μmol/L); alanine aminotransferase, 249 IU/L (10-40 IU/L); and alkaline phosphatase, 404 IU/L (30-135 IU/L). US disclosed dilation of intrahepatic and extrahepatic bile ducts, but ERCP was unsuccessful because of unusual distortion of the duodenum. Barium contrast radiography demonstrated a large multilobulated polypoid mass apparently arising from the proximal jejunum (A). CT revealed a 4 × 5-cm mass in the left flank and a distorted, dilated bile duct crossing the midline (B, arrow) caused by traction exerted by the mass. At laparotomy a 90 × 50 × 45-mm polyp was resected by means of a jejunal enterotomy (C, note ulcerated distal third). It arose just proximal to the major duodenal papilla, intussuscepting to lie in the jejunum. Histopathologically it was composed of Brunner's glands (D, arrows; H&E, orig. mag. ×400) without evidence of atypia, findings consistent with a diagnosis of hamartoma.

Carcinoma of the gallbladder associated with clonorchiasis: clinicopathologic and CT evaluation.

The computed tomographic (CT) features of three cases with pathologically proven adenocarcinoma of the gallbladder associated with clonorchiasis. CT scans of three cases with pathologically proven adenocarcinoma of the gallbladder associated with clonorchiasis were retrospectively reviewed. Scans were analyzed for the following parameters: (a) gross morphologic pattern (intralumenal mass lesion, mass replacing the gallbladder, focal or diffuse wall thickening); (b) contrast enhancement of the tumors; (c) associated gallstones or Chlonorchis sinensis worms; (d) direct invasion into the liver; (e) metastasis to adjacent viscera (pancreas, duodenum); (f) the extrahepatic bile duct (dilatation, metastasis, stone, C. sinensis worms); (g) the intrahepatic bile duct (dilatation); and (h) lymphadenopathy and metastasis. The gross morphologic pattern of three cases with carcinoma of the gallbladder was an intralumenal mass lesion (the least common type), whereas the patterns of infiltration and a mass replacing the gallbladder were not identified. Mild contrast enhancement of the tumors relative to the liver was demonstrated in all patients. Gallstones and C. sinensis worms were not visualized in the gallbladder and the extrahepatic bile duct. An unusual metastasis to the distal common bile duct and the pancreas was found in this series. Three cases with adenocarcinoma of the gallbladder associated with clonorchiasis showed intralumenal mass lesions within the gallbladder lumen. The cause-and-effect relation between clonorchiasis and gallbladder carcinoma is discussed.

Biliary Metal Stent as a Nidus for Bile Duct Stone

Several cases of recurrent stone formation caused by a surgical material as a nidus have been reported. Recently, we experienced one case in which a migrated metal stent might have been served as a nidus for common duct stone formation. The diagnosis was confirmed by ERCP, the stone was successfully removed with endoscopic therapy. Six years ago, she had undergone a lithotripsy using a percutaneous cholangioscopy (PTCS) because of intrahepatic cile duct stoes. Six years later, she developed abdominal pain in the right upper quadrant. ERCP revealed the dilated extrahepatic bile duct and left intrahepatic bile duct and the presence of a large elongated freely mobile filling defaet suggestive of common bile duct stone containing metal mesh in the distal common bile duct. The removed stone with endoscopic sphincterotomy was soft and dark brown in color with metal stent.

Clinical and genetic analysis of noncancerous and cancerous biliary epithelium in patients with pancreaticobiliary maljunction.

We analyzed clinical features and genetic alterations in the noncancerous and cancerous biliary lesions obtained from pancreaticobiliary maljunction (PBM) patients. Gallbladder (GB) and bile duct (BD) lesions were obtained surgically from 36 patients with PBM, and polymerase chain reaction (PCR) methods were used to examine for mutations of the K-ras gene and the p53 gene and for microsatellite instability (MSI). The 36 cases were clinically classified into two types according to whether extrahepatic bile duct dilatation was present: a congenital choledochal dilatation (CCD) group (n = 20) and a noncongenital choledochal dilatation (NCCD) group (n = 16). In the NCCD group, all 16 GB specimens exhibited hyperplastic, dysplastic, and cancerous (n = 9) lesions, but no pathological lesions were detected in the 12 BD specimens. On the other hand, in the CCD group, pathological examination revealed lesions, including 8 cancerous lesions, in 60% of the 20 GB specimens and lesions, and including 8 cancerous lesions, in 65% of the 20 BD specimens. K-ras mutations and MSI were detected in 33.3% and 0%, respectively, of 9 hyperplastic lesions, 28.6% and 85.7%, respectively, of 7 dysplastic lesions, and 60.0% and 80.0%, respectively, of 25 cancerous lesions (p <0.05; MSI in hyperplasia vs. dysplasia and cancer). There was no difference of the frequency in K-ras mutations and MSI between the NCCD and CCD groups. By contrast, p53 mutations were detected only in the cancerous GB lesions of both types, the rate being 35.3%. Genetic alterations of K-ras, MSI, and p53 are strongly associated with biliary tract cancer in PBM patients. MSI appears to contribute to carcinogenesis in the biliary tract mucosa of PBM patients, and p53 mutations may be related to the development of GB cancer in the CCD group.

Cystic dilation of extrahepatic bile ducts in adulthood: diagnosis, surgical treatment and long-term results.

To evaluate the long-term results of surgery for choledohal cyst in adulthood, a series of 13 patients over the age of 16 operated on for choledochal cyst during a period of six years and followed-up for a minimum of 3 years was analyzed. Patients with type I and IVa cysts underwent extrahepatic cyst resection and Roux-en-Y hepatico-jejunostomy. Choledochoceles (type III) were managed endoscopically. No operative mortality or morbidity occurred. Type I and III cysts showed almost ideal follow-up with no sign of stricture on HIDA scan. One type IVa cyst patients developed recurrent cholangitis due to anastomotic stricture, managed percutaneously. Whenever possible, complete cyst resection and Roux-en-Y reconstruction is the treatment of choice for all extrahepatic biliary cysts. Intra- and extrahepatic dilatations are adequately treated by extrahepatic resection and careful endoscopic or radiologic surveillance. Small choledochoceles can be safely managed by endoscopic sphincterotomy.

Clinical problems in the surgical treatment of pancreaticobiliary maljunction

The results of surgical treatment of pancreaticobiliary maljunction at our department are described. The 67 patients who underwent surgery for this disease were divided by age into an adult group (45 patients, aged 16 years and over) and a pediatric group (22 patients, aged less than 16 years). The incidence of concomitant carcinoma before surgery and the incidence and severity of postoperative cholangitis were compared between these two groups. In addition, the cell proliferating activity of the biliary tract epithelium in cancer-free patients was compared between the two groups, using the proliferating cell nuclear antigen labeling index (PCNA LI). Ten patients (all adults) were diagnosed with cancer (gallbladder carcinoma in 7 and bile duct carcinoma in 3) before surgery. The surgical techniques used for reconstruction in the cancer-free patients were: in the adult group, hepaticoduodenostomy in 9 patients, Roux-en-Y hepaticojejunostomy in 17, jejunal interposition in 8, and another technique in 1. In the pediatric group, hepatico-duodenostomy was performed in 17 patients. Roux-en-Y hepaticojejunostomy in 3, and jejunal interposition in 2. Postoperative cholangitis occurred in 6 adults (including 2 with severe form) and 1 child (mild case). The PCNA LI of the biliary tract epithelium was high compared to control findings in the biliary tract epithelium of 10 adult patients without pancreaticobiliary maljunction. In the adult group with dilated extrahepatic bile ducts (n=10 examined) this index was 11.4% for the bile duct epithelium (control, 1.5%) and 12.7% for the gallbladder epithelium (control, 1.4%). In the adult group with non-dilated extrahepatic bile ducts (n=5 examined) it was 5.9% for the bile duct epithelium and 13.1% for the gallbladder epithelium. In the pediatric group (n=10 with extrahepatic bile duct dilatation) it was 7.5% for the bile duct and 9.7% for the gallbladder epithelium. (Differences from control values were all significant.) These results suggest that surgery for this disease should be performed as early as possible and that extrahepatic bile duct excision and biliary reconstruction should be performed whether or not extrahepatic bile ducts are dilated.

Mucin-producing bile duct carcinoma originating at the hepatic hilus

We describe a mucin-producing bile duct carcinoma that was resected and analyzed pathologically. Endoscopic retrograde cholangiography disclosed amorphous filling defects in the dilated extrahepatic bile duct, suggesting that a large amount of mucin was excreted from the tumor. An intraductal amorphous filling defect showed shape change at different examination times. Pathology examination revealed a papillary tumor which showed mucus production, in the right hepatic duct. The cut section of the resected specimen showed a protuberant papillary lesion, measuring 14×14mm in diameter, forming a cystic mucous lake within the duct wall. Many cancer cells were also found in the mucous lake, the contents of which were strongly positive for mucin stain. The mucous lake developed laterally and communicated with the peribiliary glands, suggesting that the tumor had originated in these glands.

Congenital choledochal cyst: Occurrence of primary intrahepatic stones and prevention of carcinogenesis

Intrahepatic biliary stones and carcinogenesis are two major complications seen after corrective surgery for congenital choledochal cyst. The incidence of these two complications was reviewed in patients seen at out-patient clinics at a mean follow-up time of 13 years and 6 months. Intrahepatic biliary stones developed in 5 of 56 patients who had undergone a standard excisional operation; in 4 of the 5 patients, the stones were found in the preexisting intrahepatic biliary dilatation (with or without a downstream stenosis), 7–15 years postoperatively. Biliary stricture with dilatation is a putative cause of intrahepatic bile duct stones, and this hypothesis was supported here, since stones developed in all 3 of the patients who had the peculiar configuration of intrahepatic biliary dilatation and stenosis. Biliary carcinoma was not observed in any of the 56 patients who had undergone standard excision of a choledochal cyst followed by hepatico-jejunostomy, but developed in 1 of 12 patients in whom complete excisional resection of the dilated extrahepatic bile duct had not been performed. The occurrence of carcinoma in choledochal cysts is reviewed.

Anomalous arrangement of pancreaticobiliary ductal system associated with cholangiocellular carcinoma

A 66-year-old man with congenital cystic dilatation of the common bile duct (CDB; Alonso-Lej Type I) and anomalous arrangement of the pancreaticobiliary ductal system (AAPB) associated with intrahepatic bile duct cancer (cholangiocellular carcinoma; CCC) underwent an extended right hepatic lobectomy. In the resected specimen, the CCC was located in Couinaud’s segment V, with invasion to segment IV and the right hepatic duct and right portal vein. However, there was no cancer involvement of the dilated extrahepatic bile ducts, except for histologic findings of chronic inflammatory cellular infiltration and intestinal metaplasia. It is presumed that the probable mechanisms underlying carcinogenesis in CCC developing from the epithelium of intrahepatic bile ducts are the same mechanisms as those operating in carcinoma of the extrahepatic bile duct in patients with AAPB, although AAPB associated with CCC is uncommon. AAPB appeared to be related to the development of the CCC.

A microcholangiographic study of liver disease models in rats

Rats develop hepatobiliary injury due to small bowel bacterial overgrowth (SBBO) that, at specimen, resembles cholangiography sclerosing cholangitis. To better visualize the smaller bile ducts, we used microcholangiography to determine the spectrum of biliary lesions in this and five other models of liver disease. The models studied were as follows: (1) Surgically created jejunal, self-filling blind loops induce SBBO. (2) Intraperitoneal injection of a bacterial cell wall polymer, peptidoglycan-polysaccharide (PG-PS), causes granulomatous hepatitis. (3) Intraperitoneal injection of endotoxin (lipopolysaccharide) causes sinusoidal congestion and shock. (4) Bile duct ligation induces bile duct proliferation. (5) Alpha-naphthyl-isothiocyanate (ANIT) induces bile duct proliferation. (6) Carbon tetrachloride (CCl4) causes fibrosis and cirrhosis. Warmed barium sulfate, gelatin, and saline were injected in the extrahepatic bile duct. Liver slices (2 mm) underwent microradiographic techniques, and images were correlated with histology. Rats with SBBO had irregular and dilated extrahepatic bile ducts with thickened walls. Rats treated with endotoxin and CCl4 had normal microcholangiograms. Bile duct proliferation was identified following ANIT and bile duct ligation. Rats given PG-PS demonstrated irregular intrahepatic bile ducts. Microcholangiograms following SBBO and PG-PS showed similarities including focal ductal dilatation, narrowing, proliferation, and destruction. Various models of liver injury induce characteristic cholangiographic appearances. Microcholangiography is useful in examining biliary tract lesions and complements histology.