Ductal Wall Research Articles

Imaging of Ischemic Cholangiopathy Following Donation after Circulatory Death Liver Transplant.

Ischemic cholangiopathy (IC) is the leading cause of inferior long-term outcomes following donation after circulatory death (DCD) liver transplant. Biliary strictures related to IC are nonanastomotic strictures (NASs) by definition and involve the donor hepatic ducts proximal to the anastomosis, compared with postsurgical anastomotic strictures that form due to fibrotic healing. IC-related NASs can be microangiopathic with patent hepatic artery or macroangiopathic with occluded or stenotic hepatic artery. Recently, IC with NASs have been described to have four distinct patterns at imaging: diffuse necrosis, multifocal progressive, confluence dominant, and minor form, which correlate clinically with graft prognosis. Severe IC can lead to ductal wall breakdown with subsequent bile leaks that can cause significant patient morbidity, with imaging playing a vital role in diagnosis and guiding intervention. IC also predisposes the transplanted liver to biliary stasis and subsequent formation of stones, casts, and sludge. Some cases of posttransplant biliary stricturing are not IC but are a sequela of reflux cholangitis seen with choledochojejunal anastomosis. Other biliary findings in the posttransplant liver can be explained by sphincter of Oddi dysfunction that results from denervation. The authors describe and comprehensively categorize the various IC types and their imaging patterns at MRI and MR cholangiopancreatography, review the prognostic significance of these imaging patterns, and discuss imaging features of additional biliary complications associated with IC after DCD liver transplant. ©RSNA, 2024 Supplemental material is available for this article.

Periductal Mastitis, a Disease with Distinct Clinicopathological Features from Granulomatous Lobular Mastitis.

Periductal mastitis (PDM) is a chronic inflammatory lesion of the breast with an unknown etiology, and it is difficult for clinicians to differentiate it from granulomatous lobular mastitis (GLM), although they have different treatment strategies and prognosis. This study aimed to investigate the differences in their clinicopathologic features to inform treatment strategies. Between 2011 and 2020, 121 patients diagnosed with PDM and 57 patients with GLM were retrospective analysis. Patient data were extracted on demographics, clinical presentation, pathologic characteristics, treatments and clinical response. Histopathological evaluations were performed on core needle biopsy specimens. Immunohistochemical stains using antibodies against CD3, CD4, CD8, CD20, and CD138 was performed to define immune cell infiltration. PDM patients had a higher median age compared to GLM patients (38 vs 32, p<0.001). PDM was primarily located in the areolar area, while GLM predominantly affected the peripheral quadrant of the breast (56.20% vs 75.44%, p<0.001). Histopathologically, more ductal dilatation (90.08% vs 3.51%, p<0.001), ductal wall thickening (47.93% vs 1.75%, p<0.001), and ductal rupture (44.63% vs 5.26%, p<0.001) were observed in PDM. GLM presented with significantly more granuloma (94.74% vs 10.74%, p<0.001), microabscess (68.42% vs 28.93%, p<0.001), and lipid vacuole (40.35% vs 8.26%, p<0.001) formation than PDM. Immunohistochemical analysis revealed a significant presence of CD20+ B lymphocytes in PDM and a higher prevalence of CD8+ T lymphocytes in GLM, indicating differing immune responses. Treatment outcomes varied, with PDM patients responding well to surgery and anti-mycobacterial therapy, while GLM patients showed favorable responses to steroid therapy. PDM is a specific entity with a similar clinical presentation but distinct histopathological features and immune profiles to GLM. Further research is needed to elucidate the pathogenesis and optimize therapeutic approaches for these breast inflammatory conditions.

Измерение и расчет характеристик упругости стенки общего желчного протока человека

In the work, stress-strain curves in the longitudinal and annular directions were experimentally obtained and the differential elastic modules of the wall of the segment of the human common bile duct on cadaver material were determined. Knowledge of the physico-mechanical properties of the bile ducts can be used to understand the functioning of the entire human biliary system, to clarify aspects of its aging due to qualitative structural and functional changes in tissues, to diagnose diseases and for therapeutic purposes. One of the early manifestations of changes in the properties of the ductal wall caused by the development of a pathological process in it is a violation of its elasticity, which is reflected in an increase in stiffness indicators. It is established in the longitudinal direction of choledochus: kPa and kPa (regression confidence coefficient 0.99), in the annular direction – kPa and kPa (regression confidence coefficient 0.98), respectively.

S1693 Incidental Pancreatic Pseudoaneurysm Following ERCP

Introduction: ERCP is a commonly performed procedure, with up to 500,000 ERCPs performed annually. Commonly known complications include infection, pancreatitis, hemorrhage and perforation. Here we describe a case of pancreatic pseudoaneurysm (PDA) which resulted from Post-ERCP pancreatitis. Case Description/Methods: An 84-year-old female presented to hospital with vomiting, epigastric pain and increased weakness for one week after undergoing ERCP with stone removal and stent placement. On presentation, she was hemodynamically stable. Hepatic and pancreatic enzymes were within range, hemoglobin and hematocrit were stable, 12.6g/dL and 37.1%, respectively, and near patient’s baseline (13g/dL). CT Abdomen with IV contrast showed a 9mm hyperattenuating PDA in/adjacent to pancreatic head (which was new from recent MRCP). For better characterization, a CT angiogram with pancreatic protocol was performed, which redemonstrated stable 9mm PDA (Figure). Given no evidence of bleeding and improved clinical condition of the patient, no intervention was indicated, and the patient was discharged home. Discussion: Post-ERCP pancreatitis has an annual incidence of around 14%. Post-procedure pancreatic PDA is rarer still, seen in around 10% of the patients with post-ERCP pancreatitis. Irritation of arterial and ductal walls by indwelling catheter can lead to the development of both pancreatitis and PDA. Most of the previously reported cases of post-ERCP PDA were seen in sickle cell disease patients [1, 2]. Our patient is unique as she did not have sickle cell disease and did not have pancreatitis on arrival as per revised Atlanta criteria. We suspect patient developed pancreatitis prior to arrival to ED as she was symptomatic for one week after ERCP. A bleeding PDA is an emergency with high morbidity and mortality, so prompt diagnosis and treatment is imperative to prevent further complications.Figure 1.: Small 9 mm focus of enhancement at the pancreatic head concerning for pseudoaneurysm

Treatment Strategy for Chronic Obstructive Parotitis Related to Diabetes: A Retrospective Analysis of 12 Cases.

Objectives: The aim of this study was to describe our experience in treating chronic obstructive parotitis (COP) related to diabetes. Methods: Twelve patients with COP related to diabetes were selected for the study. A sialendoscope was introduced from the orifice to investigate the ductal wall and lumen. During the operation, chymotrypsin and gentamicin were injected. All patients were followed up for 6 months. Preoperative and postoperative visual analog scale (VAS) evaluations and salivary gland scintigraphy (SGS) examinations were applied to evaluate the therapeutic effect; differences were considered statistically significant at p < 0.05. Results: A sialendoscope was successfully used under local anesthesia in all members of the cohort. As shown by the endoscope, mucus plugs were the most common feature. Some adhered tightly to the ductal wall. We also found ductal congestion in some cases. The postoperative VAS scores and SGS counts were both significantly lower than the preoperative values (p < 0.05). Conclusion: Chymotrypsin administration during interventional sialendoscopy is significantly effective in the treatment of diabetes-related COP.

Treatment Strategy for Chronic Obstructive Parotitis Related to Diabetes

Objectives: The aim of this study was to describe our experience in treating chronic obstructive parotitis related to diabetes. Methods: Twelve patients with chronic obstructive parotitis (COP) related to diabetes were selected for the study. A sialendoscope was introduced from the orifice to investigate the ductal wall and lumen. During the operation, chymotrypsin and gentamicin were injected. All patients were followed up for 6 months. Preoperative and postoperative visual analog scale (VAS) evaluations and salivary gland scintigraphy (SGS) examinations were applied to evaluate the therapeutic effect; differences were considered statistically significant at P &lt; 0.05. Results: A sialendoscope was successfully used under local anaesthesia in all members of the cohort. As shown by the endoscope, mucus plugs were the most common feature. Some adhered tightly to the ductal wall. We also found ductal congestion in some cases. The postoperative VAS scores and SGS counts were both significantly lower than the preoperative values (P &lt; 0.05). Conclusion: Chymotrypsin administration during interventional sialendoscopy is significantly effective in the treatment of diabetes-related COP.

Defining Primary Sclerosing Cholangitis: Results From an International Primary Sclerosing Cholangitis Study Group Consensus Process

Defining Primary Sclerosing Cholangitis: Results From an International Primary Sclerosing Cholangitis Study Group Consensus Process

Maternal ingestion of cocoa causes constriction of fetal ductus arteriosus in rats

Maternal consumption of polyphenol-rich foods has been associated with fetal ductus arteriosus constriction (DAC), but safety of chocolate exposure in fetal life has not been studied. This experimental study tested the hypothesis that maternal cocoa consumption in late pregnancy causes fetal DAC, with possible associated antioxidant effects. Pregnant Wistar rats, at the 21st gestational day, received by orogastric tube cocoa (720 mg/Kg) for 12 h, indomethacin (10 mg/Kg), for 8 h, or only water, before cesaren section. Immediately after withdrawal, every thorax was obtained and tissues were fixed and stained for histological analysis. The ratio of the narrowest part of the pulmonary artery to the fetal ductus inner diameter and increased ductal inner wall thickness characterized ductal constriction. Substances reactive to thiobarbituric acid were quantified. Statistical analysis used ANOVA and Tukey test. Cocoa (n = 33) and indomethacin (n = 7) reduced fetal internal ductus diameter when compared to control (water, n = 25) (p < 0.001) and cocoa alone increased ductus wall thickness (p < 0.001), but no change was noted in enzymes activity. This pharmacological study shows supporting evidences that there is a cause and effect relationship between maternal consumption of cocoa and fetal ductus arteriosus constriction. Habitual widespread use of chocolate during gestation could account for undetected ductus constriction and its potentially severe consequences, such as perinatal pulmonary hypertension, cardiac failure and even death. For this reason, dietary guidance in late pregnancy to avoid high chocolate intake, to prevent fetal ductal constriction, may represent the main translational aspect of this study.

Interpretation of the mucous plug through sialendoscopy.

The purpose of this manuscript is to highlight the behaviour of mucus inside the ducts of the major salivary glands, in presence of typical pathologies, through images obtained with sialendoscopy. The authors present and comment on some sialendoscopies that show mucous plug in the ducts of the major salivary glands. In primary Sjogren's syndrome, mucous plugs confirm the qualitative anomaly of the mucins and acidification saliva. Instead, salivary calculations behave like foreign bodies that generate mechanical pressure and friction on the duct walls of major salivary glands, so mucus deposits in the duct in its defence; in case of infected stone, mucous plugs are formed also with the function of protecting the ducts from the aggression of germs. During sialadenitis, there is a conflict between mucus and bacteria which explains sialendoscopic evidence such as white duct walls and mucous plugs. The study of the salivary ducts through sialendoscopy often confirms the clinical diagnosis or hypothesize it. During its execution, it is necessary not only to liberate the ducts of the major salivary glands but also analyse the appearance of the mucous plugs and the ductal walls as they are useful to guide the physician towards diagnosis.

A Nomogram to Predict the Probability of Breast Intraductal Tumors in Patients with Nipple Discharge: A Real-World Study Based on Our 13-Year Clinical Experience.

IntroductionNipple discharge is a common symptom of breast disease. We aimed to perform a descriptive statistical analysis of the cases we evaluated and establish a model to predict intraductal tumors.Materials and MethodsWe conducted a retrospective study of patients from 2007 to 2019. In total, 1333 patients who completed the fiberoptic ductoscopy (FDS) were evaluated. The variables were analyzed by χ2 test. Logistic regression was used to analyze the relationship between the patient’s clinical characteristics and intraductal tumors and establish a predictive model. Receiver operating characteristic (ROC) curve analysis was used to assess the sensitivity and specificity of the predictive ability of the model. Calibration curves and decision curve analysis (DCA) were used to evaluate the model.ResultsPatients with spontaneous, single-duct, bloody discharge and a smooth ductal wall were more likely to be diagnosed with tumors by ductoscopy. A model was established based on five variables: age, side of discharge, spontaneous discharge status, duration of discharge, and color of discharge. The model was subsequently validated in 183 patients with complete data on the variables in the validation cohort. The area under the ROC curve (AUC) was calculated to be 0.716, indicating good predictive ability.ConclusionPatients with the clinical characteristics of unilateral, bloody, single-duct, spontaneous discharge and a smooth ductal wall were more likely to have intraductal tumors by ductoscopy. Our nomogram can effectively predict intraductal tumors in patients with nipple discharge.

A nomogram to predict the probability of breast intraductal tumors in patients with nipple discharge: A report based on our 13-year clinical experience.

e13582 Background: Nipple discharge is a common symptom of breast disease. Our aim was to perform a descriptive statistical analysis of the cases we collected and to establish a model to predict intraductal tumors. Methods: We conducted a retrospective study of patients from 2007 to 2019. The variables were analyzed by the c2 test. Univariate binary logistic regression was used to analyze the relationship between clinical features of patients. Receiver operating characteristics (ROC) were used to assess the sensitivity and specificity of the predictive ability of the model. Results: Patients with spontaneous, single duct, bloody discharge and smooth ductal wall were more likely to diagnose with tumor by ductoscopy. A model was established based on seven variables: age, side of discharge, spontaneous or not, duration of discharge, ductal wall and characteristics of discharge. It was subsequently validated in 178 patients with complete data on variables in the validation cohort. The area under ROC curve (AUC) were calculated to be 0.7024 indicating a good predictive ability. Conclusions: Patients with clinical characteristics of unilateral, bloody, single duct, spontaneous discharge and smooth ductal wall were more likely to have intraductal tumors by ductoscopy. Our nomogram can effectively predict intraductal tumors in patients with nipple discharge.

Optical coherence tomography of the pancreatic and bile ducts: are we ready for prime time?

Background and study aims First-generation optical coherence tomography (OCT) has been shown to increase diagnostic sensitivity for malignant biliary and pancreatic-duct strictures. A newer OCT imaging system, NVision Volumetric Laser Endomicroscopy (VLE), allows for in vivo cross-sectional imaging of the ductal wall at the microstructure level during endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to identify and evaluate characteristics on OCT that are predictive of benign and malignant strictures. Patients and methods Consecutive patients from six centers who underwent OCT between September 2016 and September 2017 were included in a dedicated registry. OCT images were analyzed, and nine recurring characteristics were further assessed. Final diagnosis was based on histology and/or surgical pathology. Results 86 patients were included (49 % male, mean age 64.7). OCT was performed in the bile duct in 79 patients and the pancreatic duct in seven. Nine OCT characteristics were identified: dilated hypo-reflective structures (n = 7), onion-skin layering (n = 8), intact layering (n = 17), layering effacement (n = 25), scalloping (n = 20), thickened epithelium (n = 42), hyper-glandular mucosa (n = 13), prominent blood vessels (n = 6), and a hyper-reflective surface (n = 20). Presence of hyper-glandular mucosa, hyper-reflective surface and scalloping significantly increased the odds of malignancy diagnosis by 6 times more ( P = 0.0203; 95 % CI 1.3 to 26.5), 4.7 times more ( P = 0.0255; 95 % CI 1.2 to 18.0) and 7.9 times more ( P = 0.0035; 95 % CI 1.97 to 31.8) respectively. Conclusion By providing in-vivo cross-sectional imaging of the pancreatic and biliary duct wall, OCT technology may improve sensitivity in diagnosing malignant strictures and provide standardizable criteria predictive of malignancy.

1404 Sclerotic Bone Metastasis From Cholangiocarcinoma: A Case Report

INTRODUCTION: Cholangiocarcinoma (CCA) account for 3% of gastrointestinal malignancies. Commonly it metastasizes to liver, peritoneum and lymph nodes. Rarely it metastasizes to bone with lytic lesions. We are presenting a case of metastatic CCA with sclerotic bone metastasis. CASE DESCRIPTION/METHODS: 59-year-old female with no medical history presented with diffuse abdominal pain for 2 weeks. She denied other complaints, illicit drug use, personal or family of history of malignancy. She was a 40-pack year smoker and social drinker. Vitals and physical exam were unremarkable except minimally diffuse tender abdomen. Labs revealed elevated AST, ALT, ALP and Bilirubin which were 524, 640, 2300 and 1.7 respectively. CT abdomen with IV contrast showed intrahepatic biliary ductal dilatation and prominence of the common hepatic duct with abrupt tapering of the duct proximal to a small, high density mass versus short segment ductal wall thickening, normal Pancreatic duct and widespread sclerotic bone lesions. MRCP showed 3 cm long nonspecific stricture involving the mid CBD regional to the insertion of the cystic duct. No associated mass or abnormal enhancement with moderate intrahepatic biliary duct dilatation in both liver lobes. CA 19-9, CEA, and AFP were elevated to 492, 700, and 7 respectively. Bone scan showed extensive diffuse increased activity over multiple focal areas within the calvarium, sternum, bilateral ribs, scapulae, entire spine, pelvis, diffusely involving most femurs. ERCP with spyglass was done along with brush biopsy and metal stent placement. Biopsy samples were not adequate for tissue diagnosis. Iliac crest biopsy was sent for pathology, immunohistochemistry (IHC), flow cytometry and chromosome analysis which showed metastatic adenocarcinoma, by IHC (pankeratin+ CK7+, CK20+, MOC31+, CK19+, CA19-9+) most compatible with pancreatobilliary primary. Flow cytometry did not show any evidence of myeloproliferative disorder and chromosome analysis could not be done due to nondividing cells. Pt underwent palliative chemotherapy for metastatic CCA with gemcitabine and cisplatin. DISCUSSION: Metastatic CCA to the bone is rare. In the few case reports describing this finding, bony lesions are usually lytic in nature. Sclerotic bone metastasis from CCA has never been reported in literature. Prognosis is extremely poor due to the minimal response to conventional chemotherapy or radiotherapy, symptom control, particularly pain, is the mainstay of treatment for improving the quality of life of the patients.

1398 A Stone in the Wall: Extraction of an Embedded Choledocholithiasis in the Proximal CBD by Cholangioscopy

INTRODUCTION: Primary choledocholithiasis are stones formed in the common bile duct as opposed to secondary stones when they originate in the gallbladder and pass through. Symptomatic choledocholithiasis are usually managed by cholecystectomy but the CBD stones post cholecystectomy are not uncommon. The rate of recurrence of symptomatic CBD stone range from 4% to 24%. Having a stone impacted in the wall has never been reported before. CASE DESCRIPTION/METHODS: A 74-year-old man with a history of cholecystectomy for symptomatic cholelithiasis presented for one-year history or right upper quadrant colicky pain. He had recurrent CBD stones for four years before presentation. He underwent multiple endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stones removal multiple times. He had a CBD stent. Medical history is also relevant for atrial fibrillation on rivaroxaban and CAD on aspirin. Upon initial evaluation vitals were stable, physical examination was only relevant for RUQ abdominal tenderness. Imaging including computed tomography scan and an ultrasound revealed stable CBD dilation at 1.1 cm with no stones or intrahepatic biliary duct dilation. ERCP was performed with a cholangiogram showing multiple small filling defects in the CBD consistent with small stones. Sludge and stones were removed using a biliary stone extraction balloon. The duct was swept multiple times and no more stones were noted. The pain did not resolve. A repeat ERCP with a cholangioscopy using the spyglass system was performed. It revealed a normal CBD ductal walls, however closer to the bifurcation of the cystic duct, a small stone was noted; it was impacted in the wall. It was retrieved using a spyglass forceps. DISCUSSION: CBD stones are common after cholecystectomy. They are formed in the bile duct in situ and usually occur 12 months after surgery. Risk factors are the presence of multiple CBD stones and type 1 or 2 periampullary diverticulum. Cholangioscopy is sometimes needed as in our case to check for any stone that is impacted or left in the proximal common bile duct.

Recurrence After Resection for Intraductal Papillary Neoplasm of Bile Duct (IPNB) According to Tumor Location

BackgroundNo studies have yet analyzed the characteristics of recurrence after resection for intraductal papillary neoplasm of bile duct (IPNB) based on tumor location. We analyzed the patterns, timing, and risk factors for recurrence. MethodsFrom 1994 to 2014, data from 103 patients who were diagnosed with IPNB were retrospectively reviewed. Among these, 44 were extrahepatic IPNB (E-IPNB) and 59 were intrahepatic IPNB (I-IPNB). ResultsCK20, pancreaticobiliary type, tumor invasion beyond ductal wall, tumor invasion to adjacent organs, and invasive disease were more frequently found in E-IPNB than in I-IPNB (22.7 vs. 8.5%; p = 0.043, 38.6 vs. 23.7%; p = 0.050, 20.5 vs. 11.9%; p < 0.001, 4.5 vs. 1.7%; p < 0.001 and 93.2 vs. 55.9%; p < 0.001). E-IPNB has poorer 5-year recurrence-free survival (RFS) compared to I-IPNB (51.7 vs. 91.4%; p < 0.001). There was no significant difference in the rate of initial isolated locoregional recurrence and initial distant recurrence according to tumor location (14.6 in E-IPNB vs. 3.0% in I-IPNB; p = 0.123, 19.5 in E = IPNB vs. 12.0% in I-IPNB; p = 0.136). Recurrence rate according to timing was different between E-IPNB and I-IPNB: within 1 year (33.3% vs. 83.3%; p = 0.061) and 1–3 years (50.0% vs. 0%; p = 0.052). The independent prognostic factors for RFS were tumor location (p = 0.034) and lymph node metastasis (p = 0.013). ConclusionsE-IPNB has a worse prognosis than I-IPNB. Different follow-up schedules for surveillance according to tumor location are needed after surgery.

The Impact of MDCT and Endoscopic Transpapillary Mapping Biopsy to Predict Longitudinal Spread of Extrahepatic Cholangiocarcinoma

BackgroundsWe aimed to investigate the diagnostic accuracy of multidetector-row computed tomography (MDCT), mapping biopsy, and other imaging modalities to predict the longitudinal extension and depth of invasion of extrahepatic cholangiocarcinoma at possible surgical ductal margins. MethodsOf 102 patients with surgical resection of extrahepatic cholangiocarcinoma between January 2010 and October 2015, 32 evaluated by multidetector-row computed tomography (MDCT) performed before biliary drainage and mapping biopsy were enrolled. Mapping biopsies were performed at 74 sites to determine the resection point of the bile duct (at 74 possible surgical ductal margins). Diagnostic accuracy was evaluated by histopathology. ResultsThe diagnostic accuracy of MDCT for longitudinal cancer spread was 79.7%, that of biopsy was 73.0%, and combining the two modalities showed highest accuracy (83.8%). The depth of tumor invasion could be predicted by combination of the ductal wall thickness and contrast enhancement on MDCT, that is, at 11 of 13 sites (84.6%) with submucosal invasion, ductal wall thickness was > 2.5mm with high contrast enhancement. ConclusionsMDCT demonstrated highest accuracy of diagnosing longitudinal extension at possible surgical ductal margins in patients with extrahepatic cholangiocarcinoma. The depth of tumor invasion could be predicted by ductal wall thickness and contrast enhancement of MDCT.

Design of a novel miniature breast biopsy needle for ductoscopy

Background. The majority of the benign and malignant lesions in the breast arise from the ductal epithelium and terminal ductlobular unit. A minimally invasive procedure called ductoscopy is able to visualize these lesions as it inspects the ductal epithelium using a small micro-endoscope. Unfortunately, it is currently challenging to obtain a tissue sample during ductoscopy and reach the most distal duct. Methods. In this study we have, therefore, developed a novel miniature (Ø1.2 mm) biopsy needle that can be used during ductoscopy. This biopsy needle consists of two coaxial counter-rotating hollow blades with a distal cutout to resect lesions from the ductal wall. Three cutouts were manufactured resulting in a beveled, straight, and reverse-beveled blade. The blades were actuated using a novel mechanism containing two helical paths that allows for the counter-rotating motion of the blades at different velocities. In a proof-of-principle experiment, the performance of the biopsy needle was evaluated using a polymeric duct model and gelatin tissue phantom. Results. During the experiment, the straight and reverse-beveled blades were able to obtain a sufficiently large tissue sample for histopathological examination. Based on these promising results, a second experiment was performed in which the micro-endoscope was integrated in the needle and we were able to take a biopsy from a chicken breast. Conclusions. In a future clinical instrument, the biopsy needle will be miniaturized and optimized to allow for an efficient, safe, and effective intraductal biopsy procedure without the need for an invasive excisional biopsy procedure.

Liver disease associated with leptospirosis in a mare

A nine-year-old Trakehner mare was presented as an emergency due to colic, and with a history of intermittent fever and poor performance. A questionable titre for Leptospira interrogans serovars Bratislava (L. Bratislava) and Pomona and a negative titre for Babesia caballi were documented. Clinical examination revealed tachycardia, pyrexia, delayed capillary refilling time, reduced gastrointestinal borborygmi, copious reflux upon nasogastric intubation, and no abnormalities upon per-redum abdominal palpation. Trans-abdominal ultrasonography revealed congestion of the biliary tree with thickening of the ductal walls, and distention and amotility of the duodenum. Severe neutrophilic leucocytosis, liver enzyme elevation, increased bile acids, hypertriglyceridaemia, total hyperbillirubinaemia, hyperproteinaemia and hyperglycemia were present. A positive titre for L. Bratislava and Australis, and a negative titre for L. Pomona were identified. Intravenous fluid therapy was initiated and the volume of nasogastric reflux gradually declined overnight; no further colic signs were observed. A liver biopsy was obtained and histological findings included severe hepatic fibrosis with bile duct proliferation and cholestasis, multifocal mild neutrophilic hepatitis, and hepatosis with glycogen storage. Aerobic and anaerobic bacterial cultures were negative. Repeated blood analysis after one week demonstrated an increase in antibody titres against L. Bratislava and further increase in gamma-glutamyltranferase (GGT) and alkaline phosphatase. A presumptive diagnosis of liver disease associated with leptospirosis was made and therapy with procaine penicillin initiated. The mare remained clinically stable and was discharged with instructions to continue therapy for an additional 2 weeks. Six weeks after discharge the mare had remained clinically stable and all but one liver parameter had normalised. The antibody titre against L. Bratislava had declined to undetectable levels. Six months after discharge a complete recovery with return to previous performance levels was reported. Though extensively described in various other animal species, as well as in humans, the association between liver disease and leptospirosis in horses is poorly characterised. Despite the lack of a strong association between liver damage with Leptospira spp. infection in horses, leptospirosis due to acute infection or potential recrudescence of leptospiraemia should be considered a differential diagnosis in cases with clinical signs and laboratory abnormalities compatible with hepatopathy, as well as in horses with chronic, recurrent, mild fever. This case report describes the history, clinical presentation, diagnostic test results and response to treatment that support a diagnosis of Leptospira-induced hepatopathy in a mare.

Balloon Dilatation of the Minor Duodenal Papilla Up to 4 mm is Safe in a Porcine Model.

Balloon dilatation of the minor duodenal papilla is a treatment option for symptomatic pancreas divisum. The histologic effects of balloon dilatation have not yet been evaluated. The aim of this study is to investigate the tolerated extent of dilatation of the minor papilla. A dilatation of the minor papilla was performed in freshly explanted pancreas of pigs using biliary balloon dilatators. Three organs were not dilated (control group), in each 8 organs a dilatation of 4, 6, and 8 mm, respectively, was performed. Tissue damage was assessed by microscopic evaluation. Ductal wall disruption and perforation as well as a semiquantitative inflammation score was described and compared. Ductal wall disruption was increased by dilatation of 6 (5/8; P=0.019) and 8 mm (6/8; P=0.006) compared with 4 mm (1/8). Median inflammation score was 0 (0 to 0), 1 (0 to 2), and 1 (0 to 2) for dilatation of 4, 6, and 8 mm, respectively (4 vs. 6 mm, P=0.007; 4 vs. 8 mm, P=0.026). No perforation occurred in the 4 (0/8) and 6 mm (0/8) group, 1 perforation occurred in the 8 mm group (1/8). A dilatation of up to 4 mm seems to be safe. However, dilatation of the minor papilla from 4 mm onwards is increasingly associated with tissue damage. These findings should be considered in endoscopic procedures dilating the minor duodenal papilla.

In vitro Assessment of Calcium Hydroxide Removal from Endo Blocks by Simple Irrigation with NaOCl and the Passive Ultrasonic Irrigation Technique

Because endodontic pathology is caused due to bacterial contamination of the root canal system, endodontic treatment should focus on eliminating microorganisms in root canals. For more than 70 years Calcium Hydroxide has an important role in antimicrobial endodontic therapy. The use of calcium hydroxide is limited by the incomplete removal thereof, a residue covering 20% to 45% of the ductal wall, even after irrigation with NaOCl or EDTA. This study aims to evaluate the removal of calcium hydroxide in root canals using two different techniques.