Magnetic Resonance Cholangiogram Research Articles

S2969 Distinction Between Mitochondrial Antibody Positive and Negative Primary Biliary Cholangitis: Case Report and Literature Review

Introduction: Anti-mitochondrial antibody-positive primary biliary cholangitis (AMA-pos PBC) is an autoimmune disorder in which monoclonal antibodies are produced against epitopes with in the mitochondrial membranes of biliary epithelial cells, resulting in progressive non-suppurative biliary cholangitis. Up to 5 % of PBC patients lack these auto antibodies, termed as anti-mitochondrial antibody negative (AMA-neg) PBC. This is a somewhat new entity and a variant of AMA-pos PBC but not an overlap syndrome. There have not been good studies describing this phenomenon or associated terminology in the literature. Case Description/Methods: An 87-year-old woman was referred to our clinic after her medical oncologist found elevated isolated levels of serum alkaline phosphatase (714 units/L). She reported fatigue but denied any other symptoms. The physical examination was benign, except for bilateral lower extremity swelling secondary to lymphedema. Her serum alkaline phosphatase level decreased to 413 units/L after an initial dose of prednisone 40 mg daily, and she was maintained on 10 mg daily. Her antinuclear antibody titer was greater than 1:2560 in a centromere pattern. Anti- mitochondrial antibody was not detected. Total IgG level was 871 mg/dL (normal, < 1600 mg/dL), serum anti-smooth muscle antibody was negative, and the hepatitis panel was normal. Computed tomography of the abdomen and pelvis without contrast showed normal liver parenchyma and no acute intra-abdominal pathology. Histopathological examination indicated florid duct lesions. Background parenchyma showed no significant steatosis, and the inflammatory changes were limited primarily to the portal areas. Periodic acid-Schiff staining highlighted the intact hepatic parenchyma and architecture. The patient was diagnosed with AMA-neg PBC and responded well to Urosdeoxycholic acid therapy. (Figure) (Table). Discussion: This case highlights the importance of recognizing AMA-neg PBC as a variant of AMA-pos PBC and being able to differentiate them. Autoimmune cholangitis is a vague and imprecise term that cannot be used in this context. All AMA-negative PBC patients should be tested for other PBC-specific autoantibodies. Although prognosis and bile duct damage and loss are worse in AMA-neg PBC for unknown reasons, treatment remains the same for both.Figure 1.: A: The position of AMA-neg PBC in the spectrum of autoimmune hepatobiliary cholangiopathy PBC, primary biliary cholangitis; ANA, antimitochondrial antibody; IgM, immunoglobulin M; UDCA, ursodeoxycholic acid; AMA-neg, antimitochondrial antibody negative; ANA, antinuclear antibodies; IgG, Immunoglobulin G; ASMA, anti-smooth muscle antibody; anti-LKM-1, anti-liver kidney microsomal antibodies; Anti-LC-1, anti-liver cytosol antibodies; anti-SLA/LP antibodies, anti-soluble liver antigen/liver pancreas antibodies; MRCP, magnetic resonance cholangiogram; ERCP, endoscopic retrograde cholangio-pancreatogram. B and C:Two photomicrographs showing histologic features typical of the florid duct lesion seen in primary biliary cholangitis.. The portal areas show granulomatous inflammation and lymphocytic cholangitis of the bile ducts (pointed yellow arrows) (hematoxylin and eosin stain, 200X original magnification). Table 1. - Diagnostic criteria of AMA-Pos PBC The diagnosis of AMA-pos PBC can be established when two of the criteria listed in Table 1 are met[5] Evidence Criteria 1) Biochemical evidence of cholestasis Elevated alkaline phosphatase levels 2) Serological:AMA-Pos PBCAMA-Neg PBC Mitochondrial antibody positiveMitochondrial antibody negative/Presence of other PBC specific autoantibodies i.e., sp100 or gp210 3) Histopathological Nonsuppurative destructive cholangitis and destruction of interlobular bile ducts.

Redo-laparoscopic cholecystectomy: is it applicable

Background Laparoscopic cholecystectomy is the treatment of choice for symptomatic gall stone disease. Laparoscopic cholecystectomy is done worldwide by general surgeons, but difficult cases remain challenging even to experts in laparoscopic surgery. Redo-cholecystectomy is done owing to either interval cholecystectomy after first surgery or stone in cystic duct stump or remnant gall bladder. The most important investigation done for the patients is magnetic resonance cholangiogram. Redo-surgery is applicable to be done laparoscopic. Patients and methods A retrospective study was conducted on 11 patients whom underwent to cholecystectomy either open or laparoscopic, where one case could undergo cholecystostomy by Foley’s catheter and second one could not reach the gall bladder, and nine cases could undergo laparoscopic (four cases postpone from the start and five cases have remnant of gall bladder or retained stone in it). Clinical examination, laboratory, and radiological evaluation was done. All cases of redo-surgery were by laparoscopy. Results One case needed to convert to open surgery. Time of surgery ranged from 1 to 3 h. There is no bile leakage or common bile duct injury. There were two cases of intraoperative bleeding and one case with postoperative bleeding. Postoperative stay in hospital was 1–2 days, except a case that was converted to open, which had 3 days of hospital stay. Conclusion Redo-laparoscopic cholecystectomy is applicable and safe but needs experience in laparoscopic skills.

Anatomic variations of the intra-hepatic biliary tree in the Caribbean: A systematic review.

BACKGROUNDIn the classic descriptions of the human liver, the common hepatic duct forms at the confluence of left and right hepatic ducts. Many authors have documented variations in the intra-hepatic ductal system, but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations.AIMTo evaluate the variations in bile duct anatomy using magnetic resonance cholangiography (MRC) in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean. Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders.METHODSThis study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean. We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1, 2017 to March 31, 2019. Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang’s classification. A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant. The variants in our population were compared to the global population.RESULTSThere were 152 MRCs evaluated in this study in 86 males and 66 females. There were 109 (71.7%) persons with “classic” biliary anatomy (type A1) and variants were present in 43 (28.3%) persons. There was no statistical relationship between the presence of anatomic variants and gender or ethnicity. We encountered the following variants: 29 (19.1%) type A2, 7 (4.6%) type A3, 6 (3.95%) type A4, 0 type A5 and a single variant (quadrification) that did not fit the classification system. Compared to the global prevalence, our population had a significantly greater occurrence of A1 anatomy (71.7% vs 62.6%; P = 0.0227) and A2 trifurcations (19.1% vs 11.5%; P = 0.0069), but a significantly lower incidence of A3 variants (4.61% vs 11.5%; P = 0.0047).CONCLUSIONThere are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics. Specifically, persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.

Prevalence and long‐term outcome of sub‐clinical primary sclerosing cholangitis in patients with ulcerative colitis

Primary sclerosing cholangitis (PSC) is closely associated with inflammatory bowel disease, particularly ulcerative colitis (UC), with an increased risk of biliary and colorectal malignancy. We sought to clarify the prevalence, characteristics and long-term outcome of sub-clinical PSC diagnosed by magnetic resonance cholangiogram (MRC) in patients with UC and normal liver biochemistry, with or without colorectal dysplasia (CRD). In this prospective case-control study, 70 patients with UC and normal liver function (51 extensive UC, 19 CRD), 28 healthy volunteers (negative controls) and 28 patients with PSC and cholestasis (positive controls) underwent MRC and blood evaluation. MRC scans were interpreted blindly by two radiologists who graded individually, the scans as definitive for PSC, possible for PSC or normal. Clinical outcome was assessed by blood monitoring, abdominal imaging and endoscopic surveillance. 7/51 (14%) with extensive UC and 4/19 (21%) with CRD had biliary abnormalities on MRC consistent with PSC. 7/11 (64%) with sub-clinical PSC had isolated intrahepatic duct involvement. Sub-clinical PSC was associated with advanced age (P=.04), non-smoking (P=.03), pANCA (P=.04), quiescent colitis (P=.02), absence of azathioprine (P=.04) and high-grade CRD (P=.03). Inter-observer (kappa=0.88) and intra-observer (kappa=0.96) agreement for MRC interpretation was high. No negative controls were assessed as definite PSC, 4/28 were considered on blinding as possible PSC. During follow-up of sub-clinical PSC (median 10.1(3.1-11.9) years), four patients developed abnormal liver biochemistry, two had radiological progression of PSC and seven developed malignancy, including two biliary and one colorectal carcinoma. Prevalence of sub-clinical PSC appears high in patients with extensive UC and normal liver biochemistry, with or without CRD. Disease progression and malignancy were identified on long-term follow-up. MRC should be considered for all patients with extensive UC or CRD to stratify surveillance.

Prevalence and Long-Term Outcome of Sub-Clinical&amp;nbsp;Primary&amp;nbsp;Sclerosing Cholangitis in&amp;nbsp;Patients with&amp;nbsp;Ulcerative Colitis

Background: Primary sclerosing cholangitis (PSC) is closely associated with inflammatory bowel disease, particularly ulcerative colitis (UC), with an increased risk of biliary and colorectal malignancy. We sought to clarify the prevalence, characteristics and long-term outcome of sub-clinical PSC diagnosed by magnetic resonance cholangiogram (MRC) in patients with UC and normal liver biochemistry, with or without colorectal dysplasia (CRD). Methods: In this prospective case-control study, 68 patients with UC and normal liver function (51 extensive UC, 17 CRD), 28 healthy volunteers (negative-controls) and 28 patients with PSC and cholestasis (positive-controls) underwent MRC and blood evaluation. MRC scans were interpreted by two blinded radiologists. Clinical outcome was assessed by blood monitoring, abdominal imaging and endoscopic surveillance. Results: 7/51 (14%) with extensive UC and 4/17 (24%) with CRD had biliary abnormalities on MRC consistent with PSC. 7/11 (64%) with sub-clinical PSC had isolated intrahepatic duct involvement. Sub-clinical PSC was associated with advanced age (p=0.04), non-smoking (p=0.03), pANCA (p=0.04), quiescent colitis (p=0.02), absence of azathioprine (p=0.04), and high-grade CRD (p=0.03). Inter-observer (kappa=0.88) and intra-observer (kappa=0.96) agreement for MRC interpretation was high. During follow-up of sub-clinical PSC (median 10.1(3.1-11.9) years), 36% developed abnormal liver biochemistry, 18% had radiological progression of PSC and 64% developed malignancy, including 2 biliary and 1 colorectal carcinoma. Conclusions: Prevalence of sub-clinical PSC appears high in patients with extensive UC and normal liver biochemistry, with or without CRD. Disease progression and malignancy were identified on long-term follow-up. MRC should be considered for all patients with extensive UC or CRD to stratify surveillance. Funding Statement: Funding for this project was provided from Oxfordshire Health Services Research Committee (Grant 0851) and the Oxford Radcliffe Hospitals Charitable Fund for PSC (Grant 0528). This work was supported by the NIHR Biomedical Research Centre, based at Oxford University Hospitals Trust, Oxford. Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: Ethical approval was granted from the Oxfordshire Research Ethics Committee (Extensive UC cohort: 05/Q1606/151 and CRD cohort: 09/H0607/4). Written informed consent was obtained from each patient and control for this study.

Outcome of portosystemic shunt surgery on pre-existing cholangiopathy in children with extrahepatic portal vein obstruction.

This study was performed to assess the effect of portosystemic shunt surgery (PSS) on portal cavernoma cholangiopathy (PCC) in children with extrahepatic portal veinobstruction (EHPVO). Children with EHPVO and PCC (unfit for Meso-Rex shunt) underwent magnetic resonance cholangiogram (MRC) and magnetic resonance portovenogram (MRPV) before non-selective PSS. PCC was graded by modified Llop classification. Those with patent shunt were re-evaluated at least 6months after surgery with MRC, MRPV and compared with pre-shunt images. Twenty-five children underwent PSS (central end to side splenorenal shunt with splenectomy [n=24], mesocaval shunt [n=1]). Pre-surgery MRC showed PCC grade I in 11, grade II in 1 and grade III in 13. MRPV showed superior mesenteric vein (SMV)block in 20. Re-assessment for PCC 18 (6 to 54) months after surgery showed grade I in 6 and grade III in 19. Thus, PCC was progressive in 6 and static in 19. Density of peribiliary collaterals decreased in 5 (SMV patent, static PCC), increased in 3 and remained unchanged in 17. Splenomegaly-related problems, gastroesophageal varices and other intra-abdominal (esophageal, perisplenic and perigastric) collaterals ameliorated in all. Non-selective PSS decompresses esophago-gastro-splenic venous circuit effectively but fails to ameliorate cholangiopathy and peribiliary collaterals. Persistence of cholangiopathy is attributable to SMV block.

Magnetic resonance cholangiogram patterns and clinical profiles of ketamine-related cholangiopathy in drug users

Recreational ketamine use has emerged as an important health and social issue worldwide. Although ketamine is associated with biliary tract damage, the clinical and radiological profiles of ketamine-related cholangiopathy have not been well described. Chinese individuals who had used ketamine recreationally at least twice per month for six months in the previous two years via a territory-wide community network of charitable organizations tackling substance abuse were recruited. Magnetic resonance cholangiography (MRC) was performed, and the findings were interpreted independently by two radiologists, with the findings analysed in association with clinical characteristics. Among the 343 ketamine users referred, 257 (74.9%) were recruited. The mean age and ketamine exposure duration were 28.7 (±5.8) and 10.5 (±3.7) years, respectively. A total of 159 (61.9%) had biliary tract anomalies on MRC, categorized as diffuse extrahepatic dilatation (n = 73), fusiform extrahepatic dilatation (n = 64), and intrahepatic ductal changes (n = 22) with no extrahepatic involvement. Serum alkaline phosphatase (ALP) level (odds ratio [OR] 1.007; 95% CI 1.002-1.102), lack of concomitant recreational drug use (OR 1.99; 95% CI 1.11-3.58), and prior emergency attendance for urinary symptoms (OR 1.95; 95% CI 1.03-3.70) had high predictive values for biliary anomalies on MRC. Among sole ketamine users, ALP level had an AUC of 0.800 in predicting biliary anomalies, with an optimal level of ≥113 U/L having a positive predictive value of 85.4%. Cholangiographic anomalies were reversible after ketamine abstinence, whereas decompensated cirrhosis and death were possible after prolonged exposure. We have identified distinctive MRC patterns in a large cohort of ketamine users. ALP level and lack of concomitant drug use predicted biliary anomalies, which were reversible after abstinence. The study findings may aid public health efforts in combating the growing epidemic of ketamine abuse. Recreational inhalation of ketamine is currently an important substance abuse issue worldwide, and can result in anomalies of the biliary system as demonstrated by magnetic resonance imaging. Although prolonged exposure may lead to further clinical deterioration, such biliary system anomalies might be reversible after ketamine abstinence. Clinical trial number: NCT02165488.

The "Christmas Tree" Sign on MR Cholangiogram in Left-Sided Cholangiohepatitis.

We report the "Christmas tree" sign on the magnetic resonance cholangiogram in two patients with left-sided cholangiohepatitis.

Safety and Outcomes in 100 Consecutive Donation After Circulatory Death Liver Transplants Using a Protocol That Includes Thrombolytic Therapy.

Donation after circulatory death (DCD) liver transplantation (LT) reportedly yields inferior survival and increased complication rates compared with donation after brain death (DBD). We compare 100 consecutive DCD LT using a protocol that includes thrombolytic therapy (late DCD group) to an historical DCD group (early DCD group n = 38) and a cohort of DBD LT recipients (DBD group n = 435). Late DCD LT recipients had better 1- and 3-year graft survival rates than early DCD LT recipients (92% vs. 76.3%, p = 0.03 and 91.4% vs. 73.7%, p = 0.01). Late DCD graft survival rates were comparable to those of the DBD group (92% vs. 93.3%, p = 0.24 and 91.4% vs. 88.2%, p = 0.62). Re-transplantation occurred in 18.4% versus 1% for the early and late DCD groups, respectively (p = 0.001). Patient survival was similar in all three groups. Ischemic-type biliary lesions (ITBL) occurred in 5%, 3%, and 0.2% for early DCD, late DCD, and DBD groups, respectively, but unlike in the early DCD group, in the late DCD group ITBL was endoscopically managed and resolved in each case. Using a protocol that includes a thrombolytic therapy, DCD LT yielded patient and graft survival rates comparable to DBD LT.

Celiac disease, enteropathy-associated T-cell lymphoma, and primary sclerosing cholangitis in one patient: a very rare association and review of the literature.

Enteropathy-associated T-cell lymphoma (EATL) is a very rare peripheral T-cell lymphoma which is mostly associated with celiac disease. However, the association of primary sclerosing cholangitis and enteropathy-associated T-cell lymphoma is uncommon. Herein we report and discuss the first case of patient who presented simultaneously with these two rare diseases. It is a 54-year-old man who stopped gluten-free diet after 15 years history of celiac disease. The diagnosis was based on the histological examination of duodenal biopsy and the diagnosis of primary sclerosing cholangitis was made on liver biopsy, as well as the magnetic resonance cholangiogram. The treatment of EATL is mainly based on chemotherapy in addition to the optimal management of complications and adverse events that impact on the response to treatment and clinical outcomes, although the prognosis remains remarkably very poor.

Isolated right posterior bile duct injury following cholecystectomy: Report of two cases

Anatomic variations of the right biliary system are one of the most common risk factors for sectoral bile duct injury (BDI) during cholecystectomy. Isolated right posterior BDI may in particular be a challenge for both diagnosis and management. Herein we describe two cases of isolated right posterior sectoral BDI that took place during laparoscopic cholecystectomy. Despite effective external biliary drainage from the liver hilum in both cases, there was a persistent biliary leak observed which was not visible on endoscopic retrograde cholangiogram. Careful evaluation of images from both endoscopic and magnetic resonance cholangiograms revealed the diagnosis of an isolated right posterior sectoral BDI. These were treated with a delayed bisegmental (segments 6 and 7) liver resection and a Roux-en-Y hepaticojejunostomy respectively with good outcomes at 24 and 4 mo of follow-up. This paper discusses strategies for prevention of such injuries along with the diagnostic and therapeutic challenges it offers.

Management of Bile Duct Injury at Various Stages of Presentation: Experience from a Tertiary Care Centre.

The clinical presentation, management and outcome of all patients with bile duct injury who presented to our tertiary care centre at various stages after cholecystectomy were analyzed. The patients were categorized into three groups: group A-patients in whom the injury was detected during cholecystectomy, group B-patients who presented within 2weeks of cholecystectomy and group C-patients who presented after 2weeks of cholecystectomy. Our team acted as rescue surgeons and performed 'on-table' repair for injuries occurring in another unit or in another hospital. Strasberg classification of bile duct injury was followed. In group A, partial and complete transections were managed by repair over T-tube and high hepaticojejunostomy, respectively. Patients in group B underwent endoscopic retrograde cholangiogram and/or magnetic resonance cholangiogram to evaluate the biliary tree. Those with intact common bile duct underwent endoscopic papillotomy and stenting in addition to drainage of intra-abdominal collection when present. For those with complete transection, early repair was considered if there was no sepsis. In presence of intra-abdominal sepsis an attempt was made to create controlled external biliary fistula. This was followed by hepatico jejunostomy at least after 3months. Group C patients underwent hepaticojejunostomy at least 6weeks after the injury. The outcome was graded into three categories: grade A-no clinical symptoms, normal LFT; grade B-no clinical symptoms, mild derangement of LFT or occasional episodes of pain or fever; grade C-pain, cholangitis and abnormal LFT; grade D-surgical revision or dilatation required. Fifty nine patients were included in the study and the distribution was group A-six patients, group B-33 patients and group C-20 patients. In group A, one patient with complete transection of the right hepatic duct (type C) and partial injury to left hepatic duct (LHD) underwent right hepaticojejunostomy and repair of the LHD over stent. Two patients with type D and three patients with type E 2 injury underwent repair over T-tube and hepaticojejunostomy, respectively. In group B, all except one of the 18 patients with type A injury underwent endoscopic papillotomy and stenting. The bile leak subsided at a mean interval of 8days in all, except one patient who died of fulminant sepsis. Of the 15 patients with type E injury, five underwent hepaticojejunostomy after a minimum gap of 3months. Early repair was considered in 10 patients. Twenty patients in group C underwent hepaticojejunostomy. In a mean follow-up of 40months, the outcome was grade A in 54 patients, grade B in three patients (one from each of the three groups) and grade D in one patient (group C). The latter patient with a type E3 injury developed recurrent stricture and cholangitis necessitating percutaneous transhepatic dilatation. The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

Degree of bile-duct dilatation in liver-transplanted patients with biliary stricture: a magnetic resonance cholangiography-based study

This study assessed whether the degree of bile-duct dilatation in liver-transplanted patients is correlated with the time from intervention and the type of underlying biliary stricture. Fifty-seven 3D magnetic resonance cholangiograms (MRCs) performed on 42 liver-transplanted patients were retrospectively evaluated. Diameter was measured at the level of the extrahepatic bile duct (EBD), right hepatic duct (RHD), left hepatic duct (LHD), anterior and posterior right hepatic ducts (aRHD, pRHD) and left lateral and medial ducts (LLD, LMD). Data were stratified according to the type of biliary stricture (all types, anastomotic, ischaemic-like, mixed) and compared, on a per-examination basis: (a) between two groups based on time from transplantation using a 1-year threshold (nonlongitudinal analysis); (b) among 26 repeated examinations on 11 patients (longitudinal analysis); (c) among different stricture groups. The biliary tree was slightly dilated within 1 year from transplantation (2.9±1.3 to 6.1±3.2 mm). In general, nonlongitudinal analysis showed minimally larger duct size after 1 year (mean +1.4±0.5 mm) despite significant differences at most sites of measurement considering all types of strictures (p<0.01; Mann-Whitney U test). Longitudinal analysis showed diameter increase over time, although without statistically significant differences (p>0.01; Kruskal-Wallis test). No significant difference in bile-duct size was observed when comparing types of stricture (p>0.01; Kruskal-Wallis test). Biliary dilatation after liver transplantation is mild and develops slowly regardless of the underlying type of stricture, possibly in relation to graft properties. MRC has a potential role as first-line imaging modality for a reliable assessment of biliary dilatation and the presence of a stricture.

Hepatobiliary and Pancreatic: Traumatic bile duct neuroma

A man, aged 76, was recovering after surgery for a perforated rectosigmoid cancer. His past history included a cholecystectomy for gallstones, 17 years previously. A computed tomography scan of the abdomen showed a small enhancing nodule in the mid-bile duct. Liver function tests were normal but the serum carbohydrate antigen, 19.9 (CA19.9) level was elevated at 302 U/mL (reference <37 U/mL). A magnetic resonance cholangiogram showed eccentric wall thickening of the mid-bile duct (arrow) consistent with a bile duct neoplasm (Figure 1). At surgery, he had a hard mass, 1 cm in diameter, in the mid-bile duct and had a segmental resection with a Roux-en-Y hepaticojejunostomy. Histological examination revealed hyperplastic and disorganised nerve fibers surrounded by fibrous connective tissue (H&E x200, Figure 2). Immunohistochemical stains were positive for S100 (inset Figure 2). The diagnosis was that of a post-operative (traumatic) neuroma of the bile duct. A neuroma or traumatic neuroma is an exuberant but non-neoplastic proliferation of a nerve that occurs after injury or surgery. After biliary surgery, neuromas can occur in the cystic duct stump but neuromas involving the bile duct are rare. Macroscopically, they are small white-gray nodules that develop at the proximal end of the injured or transected nerve. Histologically, there is a haphazard proliferation of nerve tissue that includes axons, Schwann cells and fibroblasts surrounded by a fibrous capsule. Cystic duct neuromas may be a cause of biliary-type pain after cholecystectomy and, historically, one surgical option was shortening of the cystic duct stump. The results of this procedure remains unclear. More recently, an interesting case report described three patients with pain after cholecystectomy whose symptoms were aggravated by pushing on cystic duct clips with a needle guided by endoscopic ultrasound. Symptoms improved after an injection of local anesthetic and steroid into the region and 2 of 3 patients had resection of the cystic duct stump (Am J Gastroenterol, 2005; 100: 491). Whether neuromas of the bile duct cause pain remains unclear but these nodules can result in extra-hepatic obstruction. In the latter setting, the differential diagnosis can include post-operative strictures, retained stones, benign tumors and bile duct cancer. A pre-operative diagnosis of bile duct neuroma is likely to be difficult and most patients have been treated by surgery, usually with an hepaticojejunostomy. Contributed by

Prevalence and determinants of primary sclerosing cholangitis in patients with ulcerative colitis and colorectal carcinoma or dysplasia and normal liver function tests

IntroductionApproximately 2.4–7.5% of patients with ulcerative colitis (UC) may also be diagnosed with primary sclerosing cholangitis (PSC). The risk of colorectal carcinoma (CRC) or dysplasia (CRD) has been reported to...

Long‐term Treatment of Primary Sclerosing Cholangitis in Children With Oral Vancomycin: An Immunomodulating Antibiotic

Primary sclerosing cholangitis is a rare chronic cholestatic condition of unknown etiology, frequently associated with inflammatory bowel disease and characterized by diffuse fibrosing and inflammatory destruction of the intra- and/or extrahepatic biliary duct system. The study involved 14 children with primary sclerosing cholangitis confirmed by either liver biopsy, endoscopic retrograde cholangiopancreatography, and/or magnetic resonance cholangiogram. In each of the 14 cases, liver histology showed characteristic features consistent with primary sclerosing cholangitis. Eleven children had intrahepatic biliary beading and strictures (6 by endoscopic retrograde cholangiopancreatography; 5 by magnetic resonance cholangiogram). Biochemical tests of liver function including alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transpeptidase and the erythrocyte sedimentation rate were elevated for a mean 17 +/- 22 months before vancomycin treatment was initiated. All of the patients were shown to have inflammatory bowel disease histologically; 13 of those patients had clinical evidence of colitis. Oral vancomycin was given to all 14 patients. All 14 patients showed improvement in their alanine aminotransferase (P = 0.007), gamma-glutamyl transpeptidase (P = 0.005), erythrocyte sedimentation rate (P = 0.008), and clinical symptoms with oral vancomycin treatment. There was less improvement noted in the patients with cirrhosis when compared with the patients without cirrhosis. Before this study, there has not been an effective long-term treatment for sclerosing cholangitis to prevent the usual progression of this disease to cirrhosis. This study showed that oral vancomycin could be an effective long-term treatment of sclerosing cholangitis in children, especially those without cirrhosis.

The Effects of Scolicidal Agent Propolis on Liver and Biliary Tree

BackgroundThis study was designed to examine the effects of propolis on the liver and biliary system when used as a scolicidal agent. Materials and MethodsThirty Wistar–Albino rats were divided into two groups. Propolis and 0.9% saline (NaCl) were injected into the biliary tract of the rats. Three rats from control group and four rats from propolis group died within 5 days after the procedure. Blood samples of remaining 23 rats were obtained 1 week after and at the end of the experimental study for liver function tests. Six months after the procedure, retrograde and magnetic resonance cholangiography were performed and liver, common bile duct, and duodenum were excised en bloc for histopathological examination. ResultsLiver function tests were slightly elevated 1 week after the procedure and were found to be normal at the end of the sixth month in both groups. No stricture in the biliary tree was found on the retrograde and magnetic resonance cholangiograms. The tissue samples of the propolis group showed no histomorphological difference from the control group. ConclusionsPropolis may be used as a scolicidal agent even in the case of cystobiliary communication with no side effects on liver and biliary tree.

Duplicate gallbladder: an unusual case report

Duplication of the gallbladder, a rare congenital anomaly, is important in clinical practice as it may cause some clinical, surgical and diagnostic problems. In this report we present a case of duplicated gallbladder diagnosed serendipitously in a 63-year-old male patient who had previously undergone successful laparoscopic cholecystectomy (confirmed histologically) approximately a year before for gallstones. The patient was re-admitted with obstructive jaundice. An abdominal computed tomography scan and magnetic resonance cholangiogram both revealed the presence of a gallbladder, which was thereafter removed at surgery undertaken to palliate the jaundice.

Early Bile Duct Carcinoma: Comparison of Imaging Features with Pathologic Findings

To retrospectively evaluate the imaging features of early bile duct carcinoma and to compare these features with histopathologic findings. The institutional review board did not require its approval or informed patient consent for this study. Twenty-one patients (13 men, eight women; mean age, 60 years; range, 48-75 years) with early bile duct carcinoma that was surgically resected and histopathologically confirmed were included. Ultrasonography (US) was performed in 15 patients, computed tomography (CT) in 21, cholangiography in 18, and magnetic resonance (MR) cholangiography in six. Two radiologists retrospectively reviewed imaging features by consensus; they compared growth pattern of tumors, integrity of the bile duct wall that harbored the tumor, and periductal infiltration with histopathologic findings. Pathologic specimens showed intraluminal tumor growth in all cases. Tumors were confined to the mucosa in 11 patients and involved the fibromuscular layer in 10 patients. In four of the 10 intrahepatic cholangiocarcinomas, four of the five hilar cholangiocarcinomas, and six of the six extrahepatic cholangiocarcinomas, there were intraductal tumor masses and the wall of the tumor-bearing bile ducts was preserved without periductal infiltration on US and CT images. On cholangiograms and MR cholangiograms, tumors were better delineated but the wall invasion could not be evaluated. No difference in image findings was found between carcinoma confined to the mucosa and carcinoma involving the fibromuscular layer. Imaging features of early bile duct carcinoma are a tumor mass in the bile duct lumen and integrity of the tumor-bearing bile duct wall without infiltration outside the wall.

Advances in the diagnosis of cholangiocarcinoma in patients with primary sclerosing cholangitis

Advances in the diagnosis of cholangiocarcinoma in patients with primary sclerosing cholangitis