Risk of biliary surgery in patients with hyperbilirubinemia

Previous studies have suggested a direct relationship between the serum bilirubin level and the risk of operation. However, patients with high bilirubin levels are usually older and have associated conditions unrelated to jaundice that may contribute to the development of postoperative complications. We studied the courses of 98 consecutive patients who were admitted with biliary obstruction and a serum bilirubin level of 10 mg/dl or greater and underwent operation. Sixty-one had neoplastic obstructions, 26 had benign biliary strictures, 8 had choledocholithiasis, and 3 had other obstructive lesions. Comorbid factors were evaluated and assigned a score to reflect their severity. Neither age nor advanced local cancer was considered to be a comorbid factor. Biliary obstruction was treated by resection of the bile duct, the pancreas, or both in 28 patients, by bilioenteric bypass in 55 patients, and by other operations in 15 patients. Postoperatively, complications developed in 30 patients and 8 died. There was no correlation between the admission serum bilirubin level, hematocrit value, or serum albumin level and the development of complications or death. There was a strong correlation between the presence of severe associated disease and the risk of postoperative complications or death. Nineteen of 81 patients with a comorbid score below 4 had a complication compared with 11 of 17 patients with scores of 4 or higher (p less than 0.01). Two of the 81 patients with scores below 4 died compared with 6 of 17 patients with a score of 4 or higher. These findings show that postoperative deaths and serious complications in patients with severe jaundice are principally the result of uncontrolled associated disease and that jaundice per se does not contribute substantially to an undesirable outcome.

Acute cholangitis and pancreatitis associated with sulindac (clinoril)

A 68-year-old man without previous hepatobiliary or pancreatic disease was admitted after five attacks of nausea, vomiting, abdominal pain and high fever. Laboratory investigations indicated cholestatic liver disease and pancreatitis. For 1.5 years the patient had occasionally been taking a non-steroidal anti-inflammatory drug, sulindac (clinoril, MSD, New York), for osteoarthritis. On suspicion of a drug-associated disease, a rechallenge experiment was performed with sulindac. Five hours after drug administration symptoms recurred. There was a pronounced increase in serum alkaline phosphatase and amylase. A liver biopsy 3 d later showed portal tract inflammatory infiltration and abnormal interlobular bile ducts with degeneration and necrosis of the epithelium and neutrophilic infiltration of the ducts. Sulindac-induced cholangitis has not been described previously. The pathogenetic mechanism is considered to be an immunoallergic idiosyncratic reaction to the active metabolite of sulindac absorbed by the bile duct epithelium. The lesion is apparently reversible.

Primary biliary cirrhosis and ulcerative colitis

Four patients with ulcerative colitis also had primary biliary cirrhosis, as judged by compatible liver histology, positive serum mitochondrial antibody tests, and normal cholangiography (in the 3 patients in whom it was performed). Primary biliary cirrhosis may be another hepatobiliary association of ulcerative colitis, and although less common than primary sclerosing cholangitis should be considered as a cause of cholestasis in these patients.

Emergency management of choledochal cysts in adult patients

Congenital cystic dilation of the biliary tree is rarely considered as cause of cholangitis in the adult patient. Emergency operation in seven adults with unsuspected choledochal cysts resulted in reoperation in all seven. Each patient presented with right upper quadrant pain, a mass, and cholangitis or jaundice. Abdominal ultrasonography incorrectly identified the cyst as a dilated gallbladder in three of the patients. All initial emergency drainage procedures required subsequent modification to cyst excision and Roux-Y reconstruction. From review of the experience presented and the literature to date, we recommend that otherwise stable patients be managed nonsurgically and undergo endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography to plan primary single-stage excisional operation. Patients requiring emergency decompression should have cholecystostomy or choledochostomy for good control without compromising subsequent operation. At the time of excision, a technical consideration not previously reported is the presence of small daughter cysts in Calot's triangle which must be distinguished from the hepatic bile ducts. The surgical literature has frequently addressed the problems of elective surgery for choledochal cysts; however, emergency complications requiring urgent operative intervention are seldom addressed. We believe emergency intervention should correct the urgent complication without compromising the definitive surgical treatment.

Unusual variant of primary sclerosing cholangitis

Two cases of primary sclerosing cholangitis are described, in which the characteristic bile duct lesions were unusual because there was an exuberant and exaggerated fibrous replacement of the ducts which produced dense fibrotic scars in portal tracts.

AIDS-related cholangitis: radiographic findings in nine patients

Acalculous inflammation of the biliary tract is a recently reported complication of the acquired immunodeficiency syndrome (AIDS). In a 33-month period, nine men with AIDS were evaluated because of right upper quadrant and/or epigastric pain, jaundice, or abnormal liver function test results. Each patient underwent ultrasonography and endoscopic retrograde cholangiopancreatography; seven also underwent computed tomography. In eight of nine patients the imaging studies disclosed intrahepatic and extrahepatic bile duct changes identical to those seen in sclerosing cholangitis (strictures, focal dilatation, thickened duct walls). Isolated papillary stenosis and ductal dilatation were present in one patient, while eight patients had some stricturing of the distal common duct. The combination of papillary stenosis and intrahepatic ductal strictures appears unique to AIDS-related cholangitis. Endoscopic papillotomy provided variable relief to symptoms and biochemical abnormalities. Cholangitis caused by cytomegalovirus and/or Cryptosporidium infection is the proposed pathophysiologic mechanism.

Primary sclerosing cholangitis and low-dose oral pulse methotrexate therapy. Clinical and histologic response

Two patients with sclerosing cholangitis responded to low-dose methotrexate treatment. A 40-year-old man who had previously undergone total colectomy for ulcerative colitis presented with refractory erythroderma and sclerosing cholangitis. Both disorders were alleviated and have remained in remission on methotrexate, 5 mg every 12 hours three times each week (15 mg/wk). Liver function improved, bile duct scarring did not worsen, and repeat liver biopsy samples have shown striking improvement. A 60-year-old man with long-standing ulcerative colitis and repeated exacerbations of sclerosing cholangitis had a similar response to low-dose methotrexate, 2.5 mg every 12 hours three times each week (7.5 mg/wk), during a 6-year period. Recurrent episodes of cholangitis have disappeared, liver function has become normal, bile duct scarring has not worsened, and liver histologic findings have become normal. Because of the potential hepatotoxicity of methotrexate, we suggest that a prospective, randomized trial be done.

Neurobehavioral correlates of cholestatic and hepatocellular disease: differentiation according to disease specific characteristics and severity of the identified cerebral dysfunction

Subjects with three different types of hepatic cirrhosis were compared on a battery of neuropsychological tests to determine if cerebral dysfunction varied according to the type of liver disease. It was found that the manifest cognitive impairments varied according to the type and etiology of the liver disease. These findings underscore the sensitivity of neuropsychological tests in the detection of hepatic encephalopathy, particularly in cases where there are no overt clinical signs or symptoms of neurologic disturbance. They also suggest that the nature and severity of the measurable neuropsychological abnormalities may vary within patient populations depending upon the etiology of the individual's liver disease and the specific pathophysiological mechanisms involved in its progression.

Bile duct carcinoma in patients with ulcerative colitis. Relationship to sclerosing cholangitis: report of six cases and review of the literature

Six cases of bile duct carcinoma were encountered among 1207 patients with ulcerative colitis, a prevalence rate of 0.5%. The relative risk of bile duct carcinoma in patients with ulcerative colitis was 31.3. Colitis was extensive in all six patients with a mean duration of 23.2 years before the diagnosis of carcinoma. The mean age at the diagnosis of carcinoma was 38.5 years. Three patients had undergone colectomy 5-16 years earlier, and in four patients pericholangitis and sclerosing cholangitis preexisted. The tumors, histologically adenocarcinomas, were located in the common bile duct in five patients and in the hepatic duct in one. The mean survival was 11.8 months (one patient is still alive with recurrent carcinoma). Pericholangitis and sclerosing cholangitis is a frequent preexisting lesion in patients with bile duct carcinoma complicating ulcerative colitis and may be considered a premalignant lesion in these patients. Both sclerosing cholangitis and bile duct carcinoma are rare in Crohn's disease.

Endoscopic treatment of biliary duct strictures in sclerosing cholangitis: follow-up assessment of a new therapeutic approach

Endoscopic sphincterotomy was performed on 10 patients with sclerosing cholangitis to improve biliary tract drainage and to remove bile duct sludge and stones. In addition, Gruentzig-type balloons were placed endoscopically to dilate severe biliary duct strictures in eight of these patients, and endoprostheses were inserted to bridge high grade strictures in three patients. In order to assess the effectiveness of endoscopic treatment, we compared the number of hospitalizations for clinical episodes of cholangitis in this patient group for similar periods of time before and after therapy. Episodes of cholangitis requiring hospitalization decreased from 2.5 +/- 0.4 per patient in the 12 months prior to endoscopic therapy to 0.2 +/- 0.2 episodes per patient in the year following treatment and to 0.33 +/- 0.2 episodes per patient in the additional follow-up period during the second year. Liver function tests have improved significantly over the follow-up period of 19.1 +/- 2.6 months from the time of endoscopic treatment. The serum bilirubin decreased from 6.9 +/- 2.0 mg/dl to 2.7 +/- 1.4 mg/dl; serum alkaline phosphatase decreased from 959 +/- 214 IU to 385 +/- 89 IU; and serum transaminase decreased from 117 +/- 17 IU to 77 +/- 12 IU. Endoscopic treatment appears to be effective in patients with severe sclerosing cholangitis.

[Echinococcosis of the bile ducts as an unusual cause of obstructive jaundice]

A 31 year old Turkish woman patient was hospitalized with a febrile obstructive jaundice. Despite extensive diagnostics (clinical laboratory values, sonography, computed tomography and endoscopic retrograde cholangiography), emergency laparotomy had to be carried out without definitive clarification of the cause of the obstruction. Intraoperatively, bile duct infiltration by Echinococcus cysticus was established. In the further course under pharmacotherapy with mebendazole without detection of cysts in the liver and in regression of the serological parameters, there was a recurrence after half a year with suppurative obstructive cholangitis and biliary pancreatitis. The clinical picture could be controlled promptly by endoscopic papillotomy.

Sclerosing cholangitis and ulcerative colitis in a mother and her son

We present two cases, a 32-year-old mother and her 10-year-old son, both of whom had ulcerative colitis and sclerosing cholangitis. The mother had radiologic as well as pathologic evidence of both diseases, while the child's disease was demonstrated pathologically. A review of the literature indicates the rarity of sclerosing cholangitis in childhood, with no reported instances of a parent-child affliction. The hypothesis that there is a genetic component to the development of sclerosing cholangitis may be supported by this family.

Factors predicting postoperative morbidity in biliary calculi

Statistical analysis of a group of 1,114 patients operated for biliary lithiasis shows that the gravity of the disease, the nature of the complications that accompany it, the need to approach the common bile ducts (CBD) and age, stand at the origin of postoperative complications. To reduce postoperative morbidity elective surgery should be performed in cases of biliary lithiasis with paucity of symptoms during periods free of an attack and before the patient ages.

Cytomegalovirus cholangitis in a homosexual man with acquired immune deficiency syndrome

A 29-year old white homosexual man with acquired immune deficiency syndrome presented initially with right upper quadrant pain and progressive cholestasis. Diffuse mucosal irregularities were seen at endoscopic retrograde cholangiography. Histopathological examination of the gallbladder and wedge liver biopsy showed evidence of cytomegalovirus infection. A repeat endoscopic retrograde cholangiography for persistent symptoms of right upper quadrant pain and cholestasis showed progressive mucosal irregularities of the intra- and extrahepatic bile ducts consistent with progressive cholangitis. Subsequently the patient developed evidence of disseminated infection and died. Postmortem examination revealed histologic features of cytomegalovirus infection in lungs, pancreas, small bowel, adrenal glands, and liver. Immunohistochemical staining of liver confirmed the presence of cytomegalovirus infection of the biliary duct system.