Partial Biliary Obstruction Research Articles

Ultrasound‐guided percutaneous choledochocentesis in a cat with cholelithiasis, choledocholithiasis and cholangitis due to Klebsiella pneumoniae

AbstractA 13‐year‐old female cat was presented at our Veterinary Teaching Hospital with hyporexia and prostration. The animal underwent cholecystectomy 2 months previously due to partial biliary obstruction resulting from cholecystitis, multiple cholelithiasis, choledocholithiasis, dilation and tortuosity of the bile ducts. Due to the impossibility of puncturing the gall bladder and the persistence of dilation and tortuosity of the extra‐ and intrahepatic ducts identified by ultrasound, a dilated intrabiliary duct was punctured. The objective of the present study was to report the ultrasound‐guided percutaneous choledochocentesis technique, which, to our knowledge, is the first report of its performance in cats. The material was obtained for bile culture and antibiogram, which identified the bacterium Klebsiella pneumoniae, which was multiresistant to most antibiotics and uncommon in the biliary system. The technique was performed uneventfully, and was essential in the present report to assist in the presumptive diagnosis and treatment of cholangitis associated with cholelithiasis and choledocholithiasis.

Comparing the efficacy of EUS versus MRCP with ERCP as gold standard in patients presenting with partial biliary obstruction - finding a better diagnostic tool.

To evaluate the diagnostic accuracy of different imaging modalities in patients with partial biliary obstruction with no obvious aetiology on initial imaging. This is a prospective single-centre cohort study carried out at Pak Emirates Military Hospital, Rawalpindi from June 2019 to June 2021 with non-probability consecutive sampling. Patients with ages 16 to 75 years, presenting with partial biliary obstruction and undetermined aetiology on initial imaging (TUS and MRCP) were enrolled. EUS was performed for each of these patients and the case was regarded as "true positive" or "true negative" if the findings of imaging modality correlated to those of ERCP. ROC curve, sensitivity, specificity, PPV, NPV and AUC (with 95% confidence interval) were drawn for all the diagnostic tools using SPSS V. 21. A total of 65 patients were enrolled over a period of two years with male to female ratio of 1.4:1. Forty-four patients had an intermediate risk of choledocholithiasis upon preliminary evaluation whereas, 48(74%) of the participants had CBD calculi or sludge confirmed upon subsequent ERCP. Trans-abdominal ultrasound showed the lowest sensitivity (29.2%), specificity (85%), NPV 12% and PPV 93% for diagnosing CBD calculi. This was followed by MRCP with a sensitivity of 37.5%, specificity of 100%, NPV of 36.2% and PPV of 100%. EUS showed the maximum diagnostic accuracy with AUC of 1.0 and a 100% sensitivity and specificity when compared with ERCP as gold standard. EUS is superior to MRCP in terms of diagnostic accuracy as minimally invasive diagnostic tool and EUS superiority is particularly relevant in patients with intermediate risk of choledocholithiasis.

Ductular Reaction in Total and Partial Biliary Obstruction in Experimental Settings

Ductular Reaction in Total and Partial Biliary Obstruction in Experimental Settings

Partial Ligation of the Common Bile Duct Results in Reversible Cholestasis in Rats

The animal model of common bile duct ligation is very toxic; therefore, the aim of this study was to establish a new model of obstructive jaundice in rats with partial common bile duct obstruction. Male Sprague-Dawley rats were subjected to a sham operation or partial ligation of bile duct procedure. Serum biochemistry, liver histology, and expression of bile salt transporters were examined after surgery. Serum levels of aspartate aminotransferase, alkaline phosphatase, total bilirubin, and bile acids were significantly increased in the partial bile duct ligation group 3 days after surgery. However, these changes spontaneously normalized within 14 days after surgery in the partial bile duct ligation group compared with the sham group. Bile infarcts, ductular reaction, and abundant hepatocyte turnover were detected exclusively in the partial bile duct ligation group on postoperative day 3. However, these changes dramatically reversed 14 days after surgery. Bile salt transporter expression was significantly decreased at day 3 and gradually recovered in the following 2 weeks. In conclusion, the current rat model of obstructive cholestasis is reversible, representing the clinical characteristics of partial biliary obstruction, and may be used to investigate the effects of various therapeutic strategies on reversible acute cholestasis.

Hepatobiliary scintigraphy in 2014.

Cholescintigraphy with (99m)Tc-hepatobiliary radiopharmaceuticals has been an important, clinically useful diagnostic imaging study for almost 4 decades. It continues to be in much clinical demand; however, the indications, methodology, and interpretative criteria have evolved over the years. This review will emphasize state-of-the-art methodology and diagnostic criteria for various clinical indications, including acute cholecystitis, chronic acalculous gallbladder disease, high-grade and partial biliary obstruction, and the postcholecystectomy pain syndrome, including sphincter-of-Oddi dysfunction and biliary atresia. The review will also emphasize the use of diagnostic pharmacologic interventions, particularly sincalide.

PTH-054 Ercp in Patients with Mildly Raised Alkaline Phosphatase and Normal Biliary Imaging

IntroductionSerum alkaline phosphatase levels in adults range between 20 and 120 U/L. When bone disease is excluded, an elevation suggests biliary obstruction, injury to the bile duct epithelium, or cholestasis.The...

Hyperlipidemia due to Biliary Stricture After Living-Donor Liver Transplantation

Hyperlipidemia due to Biliary Stricture After Living-Donor Liver Transplantation

Nuclear medicine hepatobiliary imaging (cholescintigraphy)

Nuclear medicine hepatobiliary imaging (cholescintigraphy)

Potential Benefits of Combined N‐Acetylcysteine and Ciprofloxacin Therapy in Partial Biliary Obstruction

This study investigates the potential benefits of antibiotics and N-acetylcysteine (NAC), a mucolytic agent, in patients who are candidates for endoscopic retrograde cholangiopancreatography (ERCP) due to partial bile duct obstruction. In total, 102 patients who had choledocholithiasis and choledochal dilatations by abdominal ultrasonography were included in the study. The patients were divided into placebo and NAC therapy groups. Physiological saline (equal volume with NAC solution) and ciprofloxacin (2 × 200 mg/d intravenously) were administered to the placebo group, and NAC (1800 mg/d intravenously) and ciprofloxacin (2 × 200 mg/d intravenously) were administered to the NAC group. In both groups, treatment protocols were administered for 7 days before ERCP. Total and direct bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), C-reactive protein (CRP), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), white blood cell (WBC) count, and neutrophil percent (NE%) levels were measured before the 7-day treatment protocol. The same measurements were also evaluated before ERCP. In the NAC group, the levels of ALP, GGT, WBC, CRP, and NE% decreased significantly (P < .001), whereas a significant decrease did not occur in the placebo group. The combined usage of NAC and ciprofloxacin can be an alternative therapeutic option until ERCP is performed in partial cholestatic patients.

An Unusual Complication of a Dropped Clip During Laparoscopic Cholecystectomy

Dropped clips during laparoscopic cholecystectomy are not uncommon and although most surgeons would make attempts to retrieve them, this is not always straightforward and therefore such objects are on occasion left in the peritoneal cavity. Cystic duct clips or hemostatic clips migrating into the common bile duct after biliary surgery, although rare are well recognized and assumed to relate to improper clip application, bile leak (usually subclinical), inflammation, and subsequent necrosis, allowing the clips to erode directly into the common bile duct. We present a case of an open endoscopic clip, which was dropped at the time of an uncomplicated laparoscopic cholecystectomy, migrating into the common bile duct and causing partial biliary obstruction and its subsequently successful endoscopic removal.

Nuclear Medicine Hepatobiliary Imaging

Nuclear medicine hepatobilary imaging (HIDA) is a time proven imaging methodology that uses radioactive drugs and specialized cameras to make imaging diagnoses based on physiology. HIDA radiopharmaceuticals are extracted by hepatocytes in the liver and cleared through the biliary system similar to bilirubin. The most common indication for HIDA imaging is acute cholecystitis, diagnosed by nonfilling of the gallbladder due to cystic duct obstruction. HIDA can detect high grade biliary obstruction prior to ductal dilatation; images reveal a persistent hepatogram without biliary clearance due to the high backpressure. HIDA also aids in the diagnosis of partial biliary obstruction due to stones, biliary stricture, and sphincter of Oddi obstruction. It can confirm biliary leakage postcholecystectomy and hepatic transplantation. Calculation of a gallbladder ejection fraction after cholecystokinin infusion is commonly used to diagnose chronic acalculous gallbladder disease. Diseased gallbladders do not contract. There are many other less common but valuable diagnostic indications for HIDA imaging.

Lithocholic Acid Feeding Induces Segmental Bile Duct Obstruction and Destructive Cholangitis in Mice

We determined the mechanisms of hepatobiliary injury in the lithocholic acid (LCA)-fed mouse, an increasingly used model of cholestatic liver injury. Swiss albino mice received control diet or 1% (w/w) LCA diet (for 1, 2, and 4 days), followed by assessment of liver morphology and ultrastructure, tight junctions, markers of fibrosis and key proteins of hepatobiliary function, and bile flow and composition. As expected LCA feeding led to bile infarcts, which were followed by a destructive cholangitis with activation and proliferation of periductal myofibroblasts. At the ultrastructural level, small bile ducts were frequently obstructed by crystals. Biliary-excreted fluorescence-labeled ursodeoxycholic acid accumulated in bile infarcts, whereas most infarcts did not stain with India ink injected into the common bile duct; both findings are indicative of partial biliary obstruction. Expression of the main basolateral bile acid uptake proteins (sodium-taurocholate cotransporter and organic anion-transporting polypeptide 1) was reduced, the canalicular transporters bile salt export pump and multidrug-related protein 2 were preserved, and the basolateral transporter multidrug-related protein 3 and the detoxifying enzyme sulfotransferase 2a1 were induced. Thus, we demonstrate that LCA feeding in mice leads to segmental bile duct obstruction, destructive cholangitis, periductal fibrosis, and an adaptive transporter and metabolic enzyme response.

Correlation between hepatobiliary scintigraphy and surgery or postmortem examination findings in dogs and cats with extrahepatic biliary obstruction, partial obstruction, or patency of the biliary system: 18 cases (1995–2004)

To evaluate the usefulness of serum biochemical variables and scintigraphic study results for differentiating between dogs and cats with complete extrahepatic biliary obstruction (EHO) and those with partial EHO or patent bile ducts. Retrospective case series. 17 dogs and 1 cat. Animals that underwent hepatobiliary scintigraphy and had either surgical or postmortem confirmation of the degree of bile duct patency were included. Scintigraphic images were evaluated and biliary tracts were classified as patent, partially obstructed but patent, or obstructed. Surgery or postmortem examination was considered the gold standard for diagnosis, and compared with those findings, sensitivity and specificity of scintigraphy were calculated. With absence of radioactivity in the intestinal tract as the diagnostic criterion for EHO, the sensitivity and specificity of scintigraphic diagnosis were both 83% when final images were acquired at 19 to 24 hours, compared with 100% and 33%, respectively, when 180 minutes was used as the cutoff time. Animals with partial biliary obstruction had less intestinal radioactivity that arrived later than that observed in animals with patent biliary tracts. Animals in which intestinal radioactivity has not been observed after the standard 3 to 4 hours should undergo additional scintigraphic imaging. Findings in animals with partial biliary obstruction include delayed arrival of radioactivity and less radioactivity in the intestine. Distinguishing between complete and partial biliary tract obstruction is important because animals with partial obstruction may respond favorably to medical management and should not be given an erroneous diagnosis of complete obstruction.

Papillary neoplasms of the bile duct that mimic biliary stone disease.

Papillary tumors of the bile duct are intraductal tumors with innumerable minute, frondlike papillary projections. These tumors may be either fixed to or detached from the bile duct wall. However, because the papillary projections on the surface of papillary tumors are long and slender, the tumors are friable and slough easily. The sloughed tumor fragments may float within the bile ducts, resulting in intermittent partial biliary obstruction and mimicking bile duct stones at clinical examination and at ultrasonography (US), computed tomography (CT), and cholangiography. A tumor manifests radiologically as thickening and irregularity of the bile duct wall or as a fixed or sloughed intraductal mass. A nonshadowing intraductal echogenic cast seen at US, an intraductal noncalcified soft-tissue mass with asymmetric wall thickening seen at CT, and an intraductal mass with a papillary surface and a serrated bile duct margin seen at cholangiography are all appearances that suggest a papillary tumor and may be helpful in differentiating a tumor from a bile duct stone.

Pressure measurements from biliary and pancreatic segments of sphincter of oddi

Using a minimally compliant infusion system and a triple-lumen pressure recording catheter, we obtained endoscopic manometric measurements from both the common bile duct and pancreatic duct segments of the sphincter of Oddi (SO) in 58 patients. Fifteen patients (ages 27-69) had the diagnosis of functional abdominal pain, 19 patients (ages 30-76) had partial biliary obstruction, and 24 patients (ages 15-80) had idiopathic acute recurrent pancreatitis. Resting ductal pressure was similar in the common bile duct and pancreatic duct in all patient groups. In the group with functional pain, basal SO pressure was similar, whether obtained from the common bile duct or pancreatic duct sphincteric segment. Eight of 19 patients with partial biliary obstruction had elevated basal SO pressure. Five of these eight patients had elevated basal SO pressure confined exclusively to the common bile duct segment of the sphincter, while three patients had elevated basal SO in both segments. Conversely seven of 24 patients with acute recurrent pancreatitis had an elevated basal SO pressure, with five patients having pressure elevation only in the pancreatic duct segment while two patients had abnormal basal SO pressure in both segments. We conclude that selective cannulation of the common bile duct and/or the pancreatic duct during manometric study of the SO is necessary in order to diagnose segmental SO dysfunction responsible for partial biliary obstruction or episodes of acute recurrent pancreatitis.

Ursodeoxycholic acid, chenodeoxycholic acid, and 7-ketolithocholic acid are primary bile acids of the guinea pig.

Guinea pig gallbladder bile contains chenodeoxycholic acid (62 +/- 5%), ursodeoxycholic acid (8 +/- 5%), and 7-ketolithocholic acid (30 +/- 5%). All three bile acids became labeled to the same specific activity within 30 min after [3H]cholesterol was injected into bile fistula guinea pigs. When a mixture of [3H]ursodeoxycholic acid and [14C]chenodeoxycholic acid was infused into another bile fistula guinea pig, little 3H could be detected in either chenodeoxycholic acid or 7-ketolithocholic acid. But, 14C was efficiently incorporated into ursodeoxycholic and 7-ketolithocholic acids. Monohydroxylated bile acids make up 51% and ursodeoxycholic acid 38% of fecal bile acids. After 3 weeks of antibiotic therapy, lithocholic acid was reduced to 6% of the total, but ursodeoxycholic acid (5-11%) and 7-ketolithocholic (15-21%) acid persisted in bile. Lathosterol constituted 19% of skin sterols and was detected in the feces of an antibiotic-fed animal. After one bile fistula guinea pig suffered a partial biliary obstruction, ursodeoxycholic and 7-ketolithocholic acids increased to 46% and 22% of total bile acids, respectively. These results demonstrate that chenodeoxycholic acid, ursodeoxycholic acid, and 7-ketolithocholic acid can all be made in the liver of the guinea pig.

Scintigraphic criteria for the diagnosis of obstructive hepatobiliary diseases with Tc-99m IDA.

The purpose of this study is to define the scintigraphic parameters that reliably predict the presence of obstructive hepatobiliary diseases. Gallbladder and intestinal visualization times noted during cholescintigraphy with Tc-99m IDA were compared to functional and morphologic parameters for their ability to accurately diagnose biliary diseases. One hundred and twenty-five normal subjects and 127 patients with five different types of hepatobiliary diseases were studied. Bile pooling in segmental ducts with minimal prolongation of excretion t-1/2 was the feature most commonly seen in partial common bile duct obstruction, and biliary nonvisualization with marked prolongation of excretion t-1/2 was the primary feature of total obstruction. Sclerosing cholangitis showed band constrictions and beading along bile ducts with regional variation in excretion t-1/2, and primary biliary cirrhosis demonstrated normal bile ducts with uniform prolongation of excretion t-1/2. Patients with cholelithiasis showed normal image patterns of the major ducts. Intestinal visualization by 60 minutes was only 46% sensitive and 77% specific with an overall accuracy of 74% in the detection of biliary obstruction. Delayed gallbladder visualization and reduction in ejection fraction were sensitive but nonspecific indicators of biliary disease. We conclude that Tc-99m-IDA imaging is an accurate test for the diagnosis of obstructive hepatobiliary disease provided both quantitative functional and qualitative morphologic parameters are analyzed. Intestinal nonvisualization at 60 minutes alone is not reliable as a sole parameter for the detection of partial biliary obstruction.

THE SYNDROME OF DISAPPEARING INTRAHEPATIC BILE DUCTS

Diseases with disappearing intrahepatic bile ducts may be developmental, immunological, infective, vascular, or chemical in origin. The immunological group includes primary biliary cirrhosis, graft-versus-host disease, and sarcoidosis. HLA class 2 antigens are displayed on the bileducts and recognition of biliary antigens by cytotoxic T-cells leads to destruction of interlobular ducts. Primary sclerosing cholangitis is associated with immunological features, but the hepatic histology is not that of immunological duct disease. The association with immunodeficiency syndromes, and the finding that secondary sclerosing cholangitis may occur in patients with the acquired immunodeficiency syndrome who are infected with cytomegalovirus, suggest that primary sclerosing cholangitis might be infective in origin. In bacterial cholangitis there is contiguity between the biliary system and the intestinal tract and usually, but not necessarily, partial biliary obstruction. Interference with the hepatic arterial supply to the bileducts leads to vascular cholangitis. Chemical cholangitis follows injection of scolicidal agents into the biliary tree. Diseases with disappearing bileducts have a long natural history and hepatocellular failure occurs late. In the late stages hepatic transplantation gives good results.

Changes in biliary lipid concentrations in bile duct obstruction: an experimental study.

Changes in biliary concentrations of bile acids, phospholipids and cholesterol and biliary pressures were measured in dogs. These parameters were studied during 7-day periods of partial biliary obstruction, of varying degrees, and after 24-hour and 48-hour periods of complete obstruction. The sample were obtained via an exteriorized but intact enterohepatic circulation allowing the introduction of varying degrees of obstruction and bile sampling. Biliary obstruction reduced the concentration of all biliary lipids especially when the obstruction produced pressures in excess of 75% of the maximum biliary secretion pressure. Only immediately after the release of a 48-hour period of complete obstruction did the risk of cholesterol supersaturation of bile occur. However, at that time there was a greatly reduced concentration of lipids in the bile and the amount of cholesterol that could potentially have precipitated was very small. It is suggested that this supersaturation would not play a significant role in the formation of gallstones.

Increased tight junction permeability: a possible mechanism of oestrogen cholestasis.

Ethinyl oestradiol increased rat biliary permeability for 3H-inulin and 14C-sucrose, and significantly raised serum concentrations of bile acids after 3 and 7 days' treatment (P less than 0.0005) and bilirubin after 7 days (P less than 0.005) but not after 3 days. Following intravenous infusion of bromsulphthalein or phenolphthalein, ethinyl oestradiol-treated rats had elevated plasma concentrations of the three bile constituents, bromsulphthalein (P less than 0.0005 after 3 and 7 days), bromsulphthalein-glutathione conjugate (P less than 0.005 after 3 days; P less than 0.0005 after 7 days) and phenolphthalein glucuronide (P less than 0.005 after 3 days; P less than 0.0005 after 7 days), but the plasma concentration of unconjugated phenolphthalein, which was undetectable in bile, was unchanged. Similar changes followed partial biliary obstruction produced by bile cannula elevation. This pattern suggests that biliary constituents are refluxing from bile to plasma via the paracellular pathway, a concept further supported by structural changes in tight junction morphology in the oestrogen-treated rats. 'Leakiness' of canalicular tight junctions may explain the pathophysiology of oestrogen-induced cholestasis.