Extrahepatic Bile Duct Dilatation Research Articles

Intrahepatic bile duct dilatation secondary to hepatocellular carcinoma: CT features in 10 patients.

To determine the computed tomographic (CT) features of bile duct obstruction secondary to hepatocellular carcinoma (HCC). CT examinations of 10 patients (mean age, 58 years) with bile duct obstruction secondary to HCC were retrospectively reviewed. All tumors were intrahepatic. Eight tumors were well-delineated and two were ill-defined. The largest diameters of tumor ranged from 1.5-6.0 cm (mean, 3.6 cm). All tumors were hypodense before contrast and did not contain calcification. After contrast, four tumors became hypodense, three were isodense, and three were hyperdense to the liver. No tumor demonstrated encapsulation. Diffuse intrahepatic bile duct dilation was observed in seven patients. One patient had extrahepatic bile duct dilatation. Localized bile duct dilatation was observed in three patients, in the hemi-liver which contained the tumor. No tumor invaded the portal vein. Although rare, HCC should be included in the differential diagnosis of bile duct obstruction. This diagnosis should be suggested in patients with bile duct obstruction when CT shows an associated intra- or extrahepatic mass. Our results suggest that HCC responsible for bile duct obstruction is remarkable for the absence of encapsulation.

99mTc-trimethyl-BrIDA Scintigraphy in HIV-related Cholangiopathy

A HIV-infected 37-year-old man with diffuse mid-abdominal pain and elevated liver enzymes was sequentially studied by sonography, computed tomography (CT), 99mTc-trimethyl-BrIDA scintigraphy and endoscopic retrograde cholangiopancreatography (ERCP). CT and sonography did not lead to a final diagnosis. Cholescintigraphy showed signs of cholecystitis and sclerosing cholangitis with intra- and extrahepatic bile duct dilatation. These findings could be confirmed by ERCP, rendering HIV-associated cholepathy probable. Cytomegalovirus infection was demonstrated by polymerase chain reaction from bile fluid and the presence of cryptosporidia infection in a histology specimen isolated by ERCP. Therefore, biliary scintigraphy seems promising for screening for HIV-associated cholangio- and cholecystopathy, being less invasive and less bothering for the patient than ERCP.

A CASE OF ANOMALOUS ARRANGEMENT OF PANCREATOBILIARY DUCT WITH STONELESS CHOLECYSTITS

This paper describes a case of anomalous arrangement of pancreatobiliary duct which was detected in a patient with stoneless cholecystitis. The patient was a 40-year-old woman complaining of upper abdominal pain. Ultrasonography visualized hypertrophy of the gallbladder wall. Endoscopic retrograde cholangio-pancreatography revealed anomalois arrangement of pancreatobility duct. Cholecystectomy and excision of the extrahepatic bile duct were carried out. Pathologically the hypertrophy of the cystic wall and mild chronic inflammatory picture were confirmed, but no heteroplasia was observed. This patient appears to belong to a high risk group for gollbladder carcinoma, because she is relatively young, there was mild dilatation of extrahepatic bile duct, and she had anomalous arrangement of pancreatobiliary duct without stones.

Obstructive dilatation of extrahepatic recipient and donor bile ducts complicating orthotopic liver transplantation: imaging and laboratory findings.

Biliary obstruction in liver transplants is most commonly due to stricture at the biliary anastomosis. The native common bile duct typically is normal. We retrospectively studied 28 patients with choledochocholedochostomy anastomoses who had marked native and donor extrahepatic bile duct dilatation associated with clinical evidence of biliary obstruction. Operative cholangiograms were compared with postoperative cholangiograms obtained a mean of 50 weeks (range, 2-246 weeks) later. Mean caliber of the native common bile duct increased from 7.5 +/- 2.0 mm on operative cholangiograms to 14.8 +/- 3.9 mm on postoperative cholangiograms (p less than .001). Mean caliber of the donor common hepatic duct increased from 5.9 +/- 1.3 mm on operative cholangiograms to 12.8 +/- 3.8 mm on postoperative cholangiograms (p less than .001). Dilatation of the cystic duct remnant was seen in 15 patients. All patients had surgical revision to choledochojejunostomy with improved results of liver function studies in most cases. Diffuse dilatation of native and donor extrahepatic bile ducts may develop in liver transplant recipients. Typical features include native and donor extrahepatic ducts greater than 12 mm in diameter and a dilated cystic duct remnant on postoperative cholangiography in a patient with otherwise unexplained hepatic dysfunction.

A CLINICAL STUDY OF CONGENITAL BILIARY DILATATION

Thirteen patients with congenital biliary dilatation treated in our department were analyzed in relation to its complications and other features. Two of the 13 patients were associated with biliary tract cancer and Both lesions were unresectable, because of their advanced stages. The dilated bile ducts appeared cystic, and the cancers involved the intrahepatic bile ducts and dilated extrahepatic bile ducts. The level of amylase in bile was high, suggesting that prolonged regurgitation of pancreatic juice into the bile ducts had induced the canceration.Concomitant cholelithiasis was found in 5 patients, 3 of whom had bilirubin calciferous stones. Morphologically, the dilated bile duct was classified as type IV-A in 3 and type Ia and Ib in each one. Stones were intrahepatic in 2 of the 3 cases of type IV-A.Pancreatic lithiasis was found in 3 patients; stones were present in the Wirsung's canal, Santorini's canal and both canals in each one. Two of the 3 had no positive stones upon roentgenography. The pancreatic stones were removed by papilloplasty or accessory papilloplasty. The 3 patients were treated by resection of the dilated extrahepatic bile duct with bile duct reconstruction. Postoperative pancreatic fistula occurred in 2 patients undergone a second operation after cystoduodenostomy or cystojejunostomy, who could be successfully managed by conservative treatment alone. Prognosis was favorable in all patients except those accompanied by cancers.

Surgical treatment of congenital dilatation of the bile duct with special reference to late complications after total excisional operation

The surgical treatment of 100 cases with congenital dilatation of bile duct with special reference to late complications was analyzed. There were no deaths nor occurrences of malignancy. Among 91 patients who had undergone the standard operation, namely total excision of the dilated extrahepatic bile duct and reconstruction after Roux-en-Y hepaticojejunostomy, there were one early complication (pancreatic juice leakage) and five late complications (four intrahepatic gallstones and one liver abscess). The cause of intrahepatic gallstone formation after a total excisional operation was attributed to the remaining intrahepatic bile duct dilatation and the stenosis located between the intrahepatic bile duct dilatation and the common hepatic duct. Accordingly, these results support the total excisional procedure for this condition; however, with regard to the cases associated with cystic dilatation of intrahepatic bile ducts, completely free bile drainage from the dilated intrahepatic biliary system should be performed at the radical operation.

Long-term results following hepatico-jejunostomy with antireflux valve construction in congenital bile duct dilatation caused by abnormal junction of the choledochus

Cystic-cylindrical dilatation of the intrahepatic and extrahepatic bile ducts occurs rarely in childhood. Aetiologically, congenital pancreaticobiliary junction anomalies play a decisive part. Accurate preoperative diagnosis is by no means an easy matter. The best possible diagnostic approach to clarify the pathologico-anatomic conditions consists in sonography coupled with on-target partial intraoperative cholangiography presenting the preduodenal section of choledochus and pancreatic duct. Between 1979 and 1987 surgery was performed at the Paediatric Surgical Department of the Municipal Paediatric Hospital of Cologne on 18 patients suffering from intrahepatic and extrahepatic cysticocylindrical dilatation of the bile ducts due to confirmed ectopic pancreaticobiliary junction anomaly. This study does not include all other types of choledochus cysts or biliary duct dilatations without proven pancreaticobiliary junction anomaly. The treatment of choice is the resection of the dilated extrahepatic biliary ducts followed by hepatico-jejunostomy using the Roux-en-Y technique. To avoid cholangitis due to reflux of intestinal contents via the shunted jejunum loop, we are constructing a two-stage anti-refluxive muscular mucosa valve in the shunted loop; this practice has been followed by us since 1983. Permanent postoperative freedom from cholangitis in 10 children after construction of the valve prompts us to recommend this procedure also in other types of bile duct surgery, especially in the treatment of atresias.

The effect of decreased portal blood flow on the biliary system

A disturbance in the regional portal blood flow adjacent to the dilated bile duct in the liver is often observed in patients with hepatolithiasis. The effects of this disturbed portal blood flow on the biliary system, with or without cholangitis, were therefore investigated. Young rabbits were divided into the following four groups; (1) controls that had a laparotomy only (n = 3), (2) those that had a ligation of the portal branch of the right posterior lobe (RP lobe) (PL) (n = 10), (3) those that had tubing inserted into the bile duct through the duodenal papilla (BS) (n = 10), and (4) PL + BS (n = 10). Despite marked atrophy of the RP lobe, no distinct changes were seen in the biliary systems of groups 1 or 2. In groups 3 and 4, however, infiltration of inflammatory cells and glandular proliferation in the wall of the markedly dilated extrahepatic bile duct (proliferative cholangitis (PC), characteristic to hepatolithiasis) were seen. Findings of PC were also noted in the intrahepatic bile duct of the atrophied RP lobes of these 2 groups. The incidence of PC was 20 per cent in group 3 and 60 per cent in group 4, respectively, but the PC of the intrahepatic bile ducts in group 3 was more localized than in group 4. Goblet cell metaplasia was seen in the epithelial cells of PC. Bacteriologically, bile samples were aseptic in groups 1 and 2, however, samples of bile from groups 3 and 4 were all contaminated with Escherichia coli or Streptococcus Faecalis. The biliary contents of phospholipids, total cholesterol and total bile acid were significantly decreased in groups 3 and 4, when compared with groups 1 and 2. In conclusion, a disturbance in portal blood flow, accompanied by cholangitis and segmental liver atrophy, may play an important role in the clinical course of hepatolithiasis.

Bile-duct dilatation after laparotomy: a potential effect of intestinal hypomotility.

Dilatation of unobstructed extrahepatic bile ducts was observed in patients with conditions associated with intestinal hypomotility. For further investigation of this association, a prospective study was undertaken in which the common hepatic duct was measured in 15 patients before and 1 day after laparotomy, when all patients had postoperative paralytic ileus. A statistically significant (p less than 0.01) increase in the mean diameter of the hepatic duct was observed postoperatively. When compared with the preoperative measurement, the mean diameter of the duct almost doubled, from 3.3 to 5.9 mm. This phenomenon may be due to persistent contraction of the sphincter of Oddi that occurs when intestinal hypomotility eliminates the stimuli for cholecystokinin release.

Congenital bile duct dilatation in children

Fifteen children under the age of 15 were identified to have congenital dilatation of the biliary tree. Thirteen of them (87%) had dilatation of both intrahepatic and extrahepatic bile ducts, while two had extrahepatic biliary dilatation only. Visualization of both intrahepatic and extrahepatic biliary tree in small children before operation is possible by ultrasonography, endoscopic retrograde cholangio-pancreatography, or percutaneous transhepatic cholangiography. The advantage and disadvantage of those methods of examinations in children are discussed here. Dilatation of intrahepatic bile ducts is common in children with extrahepatic biliary dilatation. Assessment of both the intrahepatic and extrahepatic bile ducts bears a crucial role in the management of congenital biliary dilatation at operation and during the postoperative follow-up. Rouxen-Y hepaticojejunostomy with hepaticocutaneous arm was performed in our patients with satisfactory results. Residual intrahepatic stones could be removed through the hepaticocutaneous arm by choledochoscopy.

Visualization of the pancreatic ducts by ultrasound tomography in pancreatic diseases with bile duct obstruction

The sonographic findings in 274 patients with biliary obstruction and/or dilatation of the pancreatic duct of more than 4 mm were evaluated (128 common duct stones, 82 carcinoma of pancreas, 64 chronic pancreatitis). Carcinoma of the pancreatic head caused a greater degree of dilatation of the common bile duct (average diameter 18.3 mm) than did chronic pancreatitis (10.5 mm) or biliary stones (14.2 mm). Dilatation of the pancreatic duct greater than 4 mm occurred with approximately equal frequency with carcinomas (59%) and chronic pancreatitis (64%); it was found in only 1.6% of biliary duct stones. Dilatation of intra-and extra-hepatic bile ducts and hydrops of the gall bladder was significantly higher with carcinoma of the pancreas than in chronic pancreatitis.

Pigment gallstones of the common bile duct in infancy.

Ten infants of less than 6 months of age presented with cholestatic jaundice and gallstones. Jaundice occurred after a lag period, and sepsis was present in three children. Ultrasound examination showed dilatation of intrahepatic and extrahepatic bile ducts in eight patients and detected cholelithiasis in three. Percutaneous transhepatic cholangiography and/or surgery allowed separation of the patients into two groups: (i) six children with lithiasis in the distal common bile duct, and (ii) four children with lithiasis associated with bile duct perforation at the junction between the cystic and common bile ducts with gallstones probably secondary to bile stasis and infection. Surgical treatment was confined to removal of calculi and drainage in eight children; biliary reconstructive surgery was necessary in the other two who had serious biliary duct lesions. No recurrence was observed after 1 to 7 years. The pigmentary nature of cholelithiasis was established by stone morphology in all cases, and by bile and stone analysis in several cases.

Computed tomography of primary intrahepatic biliary malignancy.

Fifteen patients with primary intrahepatic biliary malignancy (cholangiocarcinoma in 13, biliary cystadenocarcinoma in two) were examined by computed tomography (CT). The CT features were classified into three types: (A) a well-defined round cystic mass with internal papillary projections, (B) a localized intrahepatic biliary dilatation without a definite mass lesion, and (C) miscellaneous low-density masses. Intrahepatic biliary dilatation was noted in all cases of Types A and B and half of those of Type C; dilatation of extrahepatic bile ducts occurred in 4/4, 1/3, and 0/8, respectively. CT patterns, such as a well-defined round cystic mass with papillary projections or dilatation of intra- and extrahepatic ducts, give important clues leading to a correct diagnosis of primary intrahepatic biliary malignancy.

CAROLİ HASTALIĞI (İntrahepatik Safra Kanallarının Konjenital Kistik Dilatasyonu)

(Caroli's Disease : Robert of a Case) Caroli's disease is congenital malformation caracterised by localized cystic dilatation of the intrahepatic biliary tree. This condition may occur as an isolated alteration limited to the intrahepatic biliary system or may be associated with other developmental malformotions such as congenital hepatic fibrosis and the dilatation of extrahepatic biliary tree. A case of congenital cystic dilatation of the intrahepatic bile ducts is reported. The female patient was 22 years oldu. She was admitted to our surgical service, with a 2 month history of abdominal pain, accompanied by fever and jaundice. The diagnosis was establis¬hed with the operative findings especailly cholangiography. Extra-hepatic bile duct dilatation, intrahepatic stones and extrahepatic stones were also found. All of the stones were removed and than choledochoduodenostomy was carried out.

The pseudo-dilated common bile duct: ultrasonographic appearance created by the gallbladder neck.

A retrospective analysis of 111 ultrasonograms was performed in order to evaluate the relationship of the gallbladder neck to the common bile duct and portal vein. Of the 100 studies deemed technically adequate, eight contained scans that demonstrated a potentially confusing pattern of a pseudo-dilated common bile duct caused by either a redundant or folded neck of the gallbladder. Recognition of this entity as well as the use of real-time ultrasound equipment should minimize false-positive diagnoses of extrahepatic bile duct dilatation.

A Case of Congenital Cystic Dilatation of Intra-and Extra-Hepatic Bile Ducts with Stricture due to Bridgeformation in the Left Hepatic Duct

A Case of Congenital Cystic Dilatation of Intra-and Extra-Hepatic Bile Ducts with Stricture due to Bridgeformation in the Left Hepatic Duct