An update on AIDS-related cholangiopathy

Both hepatic parenchymal and biliary tract diseases are common in patients with human immunodeficiency virus (HIV). In this paper, the authors focus mainly on clinical aspects of acquired immunodeficiency syndrome (AIDS)-related cholangiopathy. Although the etiology is unclear, several opportunistic infections (cytomegalovirus, Cryptosporidium and others) are suspected to cause it. Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic gold standard and it offers a therapeutic means to provide symptomatic relief in case of papillary stenosis. The most common ERCP pattern is diffuse sclerosing cholangitis in combination with papillary stenosis. Clinically, the presentation may be variable, although right upper quadrant pain and fever accompanied by an elevated serum alkaline phosphatase (ALP) level are the most common manifestations. Jaundice is unusual suggesting that complete ductal obstruction is rare. While ERCP results and the need of sphincterotomy do not influence the prognosis, antiretroviral therapy is a protective factor and, on the contrary, high ALP level is related to a less favorable outcome. Regarding the possible pathogenic mechanisms through which HIV infection could be involved in AIDS-related cholangiopathy, in vitro experiments have shown that concurrent active HIV replication and Cryptosporidium parvum infection synergistically increase cholangiocyte apoptosis and thus jointly contribute to AIDS-related cholangiopathies.

Extrapancreatic manifestations in autoimmune pancreatitis

It is increasingly recognized that organs beyond the pancreas may be clinically involved in patients with autoimmune pancreatitis (AIP). Other gastrointestinal sites (such as the extrapancreatic biliary tree, liver, and ampulla) appear particularly affected, but involvement of many other organs (including kidneys, lungs, retroperitoneum, and brain) is increasingly reported. A similar histological lesion, characterized by an IgG4-positive lymphoplasmacytic infiltrate, affects both the pancreas and extrapancreatic tissues, strongly suggesting an aetiopathogenic link. In this review we discuss the clinical presentation and disease course, diagnostic features, and management of extrapancreatic involvement in AIP.

[Biocorrection of biliary incompetence during digestive apparatus diseases]

The diseases of the hepatobiliary system approach up to 40% among the digestive apparatus diseases. The typical characteristic for many pathologies of digestive system is biliary incompetence. Biocorrection was held by organodrugs in particular by gepatosan and enterosan during chronic pancreatitis, cholelithiasis, alcoholic liver disease, irritable colon syndrome, viral hepatitises B, postcholecystectomy syndrome. We were able to eliminate the biliary incompetence in 80-87% cases.

Inflammatory bowel disease: thinking outside of the intestines (Part 1)

Inflammatory bowel disease (IBD) can present itself in many different ways. Although it mainly affects the gastrointestinal tract, it can manifest itself practically anywhere else within the body. These extraintestinal manifestations (EMs) can occur both during active disease and when the disease is quiescent, and in some cases can precede the diagnosis of IBD. It is imperative for physicians to recognize the EMs of IBD since some of them can cause significant morbidity and mortality if left untreated. This article will review the EMs of IBD which involve the hepatobiliary, mucocutaneous, musculoskeletal and ophthalmologic systems.

[Bile duct involvement in autoimmune pancreatitis: classification and treatment]

Autoimmune pancreatitis is a rare disease characterized by inflammation of the pancreatic parenchyma, irregular narrowing of the pancreatic duct, periductal lymphoplasmacytic infiltration and fibrosis at histological examination, the presence of autoantibodies and hypergammaglobulinemia, as well as the possible association of cholangitis and other autoimmune diseases. There is a favorable response to steroid therapy. We report the case of a patient with autoimmune pancreatitis with bile duct involvement and peripheral eosinophilia, requiring long-term immunosuppressant treatment. The diagnosis of a diffuse form of AIP was made without direct histological evidence and based on indirect imaging, clinical and laboratory findings in an autoimmune context. The histological and imaging studies of bile duct involvement and the favourable response to steroids were additional arguments.

Hodgkin lymphoma-related vanishing bile duct syndrome and idiopathic cholestasis: statistical analysis of all published cases and literature review

BACKGROUND

Hodgkin lymphoma (HL)-related vanishing bile duct syndrome (VBDS) and idiopathic cholestasis (IC) are rare conditions that often lead to liver failure and death. The available literature consists primarily of case reports, resulting in little clarity as to the clinical course and ideal treatment for this disease.

MATERIAL AND METHODS

We performed a literature search from which we identified all published cases of HL-related VBDS or IC, and created a database of detailed presentation, treatment, and outcome information for all patients. Patient and disease factors were analyzed for an association with overall survival and liver failure-free survival. A case presentation introduces this analysis.

RESULTS

Thirty-seven cases of HL-related VBDS/IC were identified. Median follow-up was 7 months; 1-year OS and liver failure-free survival (LFFS) are 43% and 41%, respectively. Sixty-five percent of the patients died while 30% were alive with normal or near-normal stable liver function and no evidence of recurrent HL at last evaluation. Of the 20 patients without residual HL following therapy, 12 (60%) achieved liver failure-free survival. On univariate analysis, factors significantly associated with improved liver failure-free survival were stage I/II HL (p=0.02), a complete response of HL (p=0.0002), and delivery of radiotherapy (pB0.0001). Two patients received chemotherapy without radiation and survived with recovery of liver function.

DISCUSSION

HL-related VBDS/IC is potentially reversible and not uniformly fatal, with 30% of presenting patients demonstrating good lymphoma and liver outcomes after definitive therapy for HL. As a complete response of HL provides the only possibility of recovering liver function, patients with this disease should proceed to definitive treatment of HL as soon as feasible.

Intraductal chilled saline perfusion to prevent bile duct injury during percutaneous radiofrequency ablation for hepatocellular carcinoma

BACKGROUND AND AIM

Radiofrequency ablation (RFA) is a promising, minimally invasive treatment for hepatocellular carcinoma (HCC). However, thermal injury sometimes occurs in the bile duct, potentially leading to a critical situation. The aim of the present study was to investigate whether bile duct injury is reduced by an intraductal chilled saline perfusion (ICSP) through a nasobiliary tube during RFA for HCC.

PATIENTS AND METHODS

The baseline incidence of bile duct injury at Gifu Municipal Hospital was 3.1% (13 patients) in 424 patients with HCC treated by percutaneous RFA. In all patients, the tumor was within 5 mm of the central bile duct on CT images. The incidence of bile duct injury was 46% among the 28 selected patients whose tumor was close to the central bile duct. To prevent complications in such high-risk patients, we placed a nasobiliary tube endoscopically before RFA, and performed ICSP during RFA. Forty consecutive patients with tumors close to the central bile duct were enrolled in this study.

RESULTS

Of the 40 enrolled patients, only one had biliary injury, whereas the remaining 39 patients were able to avoid it. The incidence of biliary injury was significantly reduced in the ICSP group (1/40, 2.5%) compared to that in the control group (13/28, 46%) (P < 0.0001). Moreover, the liver function 6 months after RFA was also better preserved in the ICSP group according to Child-Pugh grading, thus resulting in a better clinical outcome.

CONCLUSIONS

ICSP through a nasobiliary tube is a potential intervention method to prevent biliary injury by percutaneous RFA.

[Classification of iatrogenic damages of biliary ducts in cholecystectomy]

While introduction of laparoscopic technologies into clinical practice the extrahepatic bile--efferent ways damages during cholecystectomy performance had increased from 0.1-0.2 to 0.4-0.7%. The necessity of elaboration of a simple and mostly complete classification of such damages had occurred. The advantages and faults of the main world-wide now existing classifications of the extrahepatic biliary ducts damages were analyzed. Classification of their own, reflecting, without unnecessary details, the majority of possible variants of the biliary ducts damages, was proposed, making it convenient for practical application.

[Pseudoaneurysm of the hepatic artery presenting with hemobilia--a complication of laparoscopic cholecystectomy]

INTRODUCTION

Hemobilia, defined as a bleeding into the bile duct, is a rare disease. One of its infrequent causes is a hepatic artery pseudoaneurysm, usually developed after arterial iatrogenic leasion.

MATERIAL AND METHODS

A case review, presenting right hepatic artery pseudoaneurysm with a biliovascular fistula as a consequence of hepatic artery and bile duct injuries during "uncomplicated" laparoscopic cholecystectomy.

DISCUSSION

Bile duct injury is one of the most serious complication after laparoscopic cholecystectomy. Hepatic artery may be injured simultaneously, resulting in the pseudoaneurysm and/or biliovascular fistula, presenting with hemobilia. Time interval from the injury to symptoms widely varies from few hours to weeks or even several months.

CONCLUSION

Melena or hematemesis after recent laparoscopic cholecystectomy should be always suspicious from hepatic artery and/or bile duct injuries, manifesting with hemobilia.

[Experimental study of relationship of bile composition imbalance with bile duct injury]

OBJECTIVE

To investigate the change of bile composition and its role in bile duct injury after orthotopic liver transplantation (OLT).

METHODS

Rats were randomly divided into 3 groups: group A (sham surgery), group B (OLT with 1 h cold preservation), group C (OLT with 12 h cold preservation). The arterialized rat liver transplantation model with biliary extra-drainage was used in group B and C. Animals were sacrificed at posttransplant 1, 3, 5, 7, 10 and 14 day. Routine bile chemistry and pathological assays were performed.

RESULTS

Cold preservation/reperfusion injury (CPRI) could repress the secretion of bile salts and phospholipid. However, in contrast with a rapid increase of bile salt secretion, the biliary secretion of phospholipid recovered more slowly, leading to an abnormal high bile salts/phospholipid ratio early after transplantation. Further analysis suggested that the secretion of bile salts correlated strongly with biochemical and histopathological signs of bile duct injury.

CONCLUSIONS

CPRI can lead to great changes of graft bile composition, which plays a role in the pathogenesis of bile duct injury following liver transplantation.

Usefulness of the "rendezvous" technique in living related right liver donors with postoperative biliary leakage from bile duct anastomosis

This is a report on two cases of large bile leak following right hepatectomy performed for living related liver transplantation, originating from the stump of the ligated right bile duct, and treated with the placement of large percutaneous biliary catheters through a combined percutaneous transhepatic and endoscopic approach (rendezvous technique).

Spontaneous perforation of the extrahepatic biliary tract

Spontaneous perforation of the extra-hepatic biliary tract presenting with pseudocyst is rare. We report the case of a two-month old infant who presented to us with increasing jaundice and progressive loss of weight. Ultrasonography, magnetic resonance cholangiopancreatography and hepatobiliary iminodiacetic acid scan revealed features of obstructed choledochal cyst. Laparotomy revealed a small, walled-offcollection of bile near the confluence of the cystic and common bile ducts. Distal obstruction was excluded and biliary tract drainage was successful in treating the infant.

[Diagnostic and follow up value of magnetic resonance cholangiography in biliary complications after orthotopic liver transplantation]

OBJECTIVE

To evaluate the diagnostic and follow up value of magnetic resonance cholangiography (MRC) in biliary complications after orthotopic liver transplantation (OLT).

METHODS

MRC was performed, using 1.5 T scanner on 166 consecutive OLT recipients. The MRC results were analyzed and compared with the confirmed diagnosis criteria (direct cholangiography, laparotomy, and liver puncture).

RESULTS

The sensitivity, specificity, accuracy, and positive and negative predictive value of MRC in diagnosis of biliary complications were 98.4%, 81.6%, 87.9%, 76.5% and 98.8%. 104 clinically normal cases and 62 symptomatic cases showed 31 and 50 MRC abnormal findings respectively. MRC totally showed 70 cases of suspected biliary complications following OLT, including 41 cases with anastomotic stricture, 8 with focal non-anastomotic stricture, and 12 with stones or debris formation, 2 with bile leak, 3 with cholangitis and 4 with oppressive changes of biliary tract. MRC also showed periportal edema in 11 cases.

CONCLUSION

A good imaging modality to show both periportal edema and biliary abnormality of various patterns, MRC provides important information for post-operational follow up and early detection of biliary complications in OLT recipients.

Classification and prognosis of intrahepatic biliary stricture after liver transplantation

Intrahepatic biliary stricture (IHBS) after liver transplantation (LT) may develop in patients with hepatic artery thrombosis, chronic rejection, or ABO incompatibility, as well as in patients with prolonged warm ischemia in non-heart-beating donor (NHBD) LT. However, the clinical course and methods of management have not been well defined for IHBSs to date. Thus, the purpose of this study was to provide a classification of post-LT IHBS and to investigate patient prognosis. Forty-four patients who developed IHBS after NHBD LT were enrolled. On the basis of the cholangiographic appearance, patients were classified into 4 groups: unilateral focal (UF, n=8), confluence (CO, n=10), bilateral multifocal (BM, n=21), and diffuse necrosis (DN, n=5). The UF type was defined as cases with stricture only in the segmental branch of the unilateral hemiliver; the CO type in cases with several strictures at confluence level; and the BM type in cases with multiple strictures bilaterally. Cases with diffuse obliteration of peripheral ducts or destruction of the central architectural integrity, over a long segment, were classified as the DN type. Five patients with the CO type required several interventions requiring biliary dilatation, yet all patients with the UF or CO type had a good prognosis. Among the patients with the BM type, 3 patients (14.3%) died or underwent retransplantation due to biliary complications, and 7 (33.3%) required repeated interventions for >1 year without improvement. Moreover, among 5 patients classified as the DN type, 1 (20%) died of biliary sepsis, 2 (40%) underwent retransplantation, and the remaining 2 (40%) did not recover from persistent jaundice and life-threatening cholangitis despite multiple interventions. In conclusion, all patients classified as UF or CO had a good outcome with or without additional interventions. However, all patients with the DN type and about half the patients with the BM type did not recover from life-threatening complications, despite repeated aggressive interventions; early retransplantation was therefore the only treatment option for these patients.

Biliary tract infection and bacteraemia: presentation, structural abnormalities, causative organisms and clinical outcomes

BACKGROUND

Biliary tract infection is a common cause of bacteraemia and is associated with high morbidity and mortality. Few papers describe blood culture isolates, underlying structural abnormalities and clinical outcomes in patients with bacteraemia.

AIMS

To determine the proportion of bacteraemias caused by biliary tract infection and to describe patient demographics, underlying structural abnormalities and clinical outcomes in patients with bacteraemia.

DESIGN

Prospective cohort study.

METHODS

Biliary tract infection that caused bacteraemia was defined as a compatible clinical syndrome and a blood culture isolate consistent with ascending cholangitis. Patients aged 16 years and over were included in the study. From June 2003 to May 2005, demographic and clinical data were collected prospectively on all adult patients with bacteraemia. Radiological and endoscopic retrograde cholangiopancreatography findings were collected retrospectively.

RESULTS

In 49 patients, the biliary tract was the site of infection for 39/592 (6.6%) community-acquired and 19/466 (4.1%) hospital-acquired episodes of bacteraemia. Three patients had mixed bacteraemias, and four had recurrent bacteraemia. The proportion of patients presenting with a structural abnormality was 34/49 (69%), and, of these structural abnormalities, 18/34 (53%) were pre-existing or newly diagnosed malignancies. Gram-negative organisms caused 55/58 (95%) episodes of bacteraemia. The most common Gram-negative organisms were Escherichia coli (34/55; 62%) and Klebsiella pneumoniae (14/55; 26%). Of the E coli isolates, 6/34 (18%) were extended spectrum beta-lactamase producers or multiply drug resistant. Thirty-day mortality was 7/49 (14%). There was no difference in time taken to administer an effective antibiotic to survivors and non-survivors (0.86 vs 1.05 days, respectively, p = 0.92). Of the seven who died, four died from septic shock within 48 h of admission caused by "susceptible" Gram-negative organisms. Two others died from disseminated malignancy.

CONCLUSIONS

The proportion of bacteraemias caused by biliary tract infection was 5.5%. The most common infecting organisms were E coli and K pneumoniae. There was a strong association with choledocholithiasis and malignancies, both pre-existing and newly diagnosed. Death was uncommon but when it occurred was often caused by septic shock within 48 h of presentation.

Vanishing bile duct syndrome in a patient with advanced AIDS

A 39-year-old HIV-infected woman developed signs and symptoms of obstructive jaundice and cholestasis. Serological tests were positive for cytomegalovirus (CMV) infection. There was no evidence of AIDS cholangiopathy in ultrasonography or magnetic resonance cholangiopancreatography (MRCP). A liver biopsy revealed marked ductopenia and the patient was diagnosed with vanishing bile duct syndrome, thought to be secondary to CMV infection as a result of profound immunosuppression. To the best of our knowledge, this is the first reported case of vanishing bile duct syndrome diagnosed in a patient with HIV/AIDS.

[Endoscopic diagnosis and treatment of biliary complications after laparoscopic cholecystectomy]

OBJECTIVE OF STUDY

The main parameters studied in this retrospective study were the success of diagnoses carried out using endoscopic retrograde cholangiopancreatography (ERCP), the ability of ERCP to precisely determine the cause of complications and the effectiveness and morbidity of therapeutic ERCP.

MATERIALS AND METHOD

the study covers a period of 7 years (January 1997-December 2003). The study retrospectively reviewed the histories of 92 patients who underwent laparoscopic cholecystectomy (LCE) and subsequently developed symptoms suggesting possible biliary complications (BC) from previous LCE, and indicating the performance of ERCP.

RESULTS

diagnostic ERCP was successful for all 92 patients (i.e. in 100% of cases). In 5 patients the ERCP found normal conditions. In the remaining 87 patients, the ERCP found pathological conditions corresponding to some form of biliary complication. Choledocholithiasis was detected in 59 patients, bile leakage from the cystic duct stump was found in 11 patients, bile leakage from the extrahepatic bile duct was found in 4 patients, biliary stenosis in the common hepatic duct was found in 5 cases and 8 patients had blockages of the extrahepatic bile duct. 10 patients out of 87 received only diagnostic ERCP and all 10 underwent surgery immediately following diagnosis. 77 out of 87 patients with established BC underwent endoscopic therapy after diagnostic ERCP. Therapeutic ERCP was entirely successful for 73 patients out of 87 with BC after LCE (83.92%), and did not require other modalities of treatment such as surgical or transhepatic procedures.

CONCLUSIONS

In our sample the success rate for therapeutic ERCP was 83.92%. Morbidity relating to therapeutic ERCP was 3.9%. ERCP was shown to be highly effective in both diagnosing and treating BC after LCE.

[Pathophysiology of cholangiocytes: recent advances]

A bulk of researches performed in the last decade highlighted the extraordinary biological properties of cholangiocytes involved in a number of important processes such as bile formation, proliferation, injury repair, fibrosis, angiogenesis and regulation of blood flow. Cholangiocytes proliferation is a key mechanism capable of conditioning the evolution of liver damage. Proliferating cholangiocytes, in fact, acquire the phenotype of neuroendocrine cells and secrete different substances which represent the tools of cross-talk with other hepatic cells. Recent advances on the molecular and cell biology of cholangiocytes are opening new potential therapeutic perspectives for the human chronic liver diseases.

Complications of liver transplantation: multimodality imaging approach

Liver transplantation is currently an accepted first-line treatment for patients with end-stage acute or chronic liver disease, but postoperative complications may limit the long-term success of transplantation. The most common and most clinically significant complications are arterial and venous thrombosis and stenosis, biliary disorders, fluid collections, neoplasms, and graft rejection. Early diagnosis is crucial to the successful management of all these complications, and imaging plays an important role in the diagnosis of all but graft rejection. A multimodality approach including ultrasonography and cross-sectional imaging studies often is most effective for diagnosis. Each imaging modality has specific strengths and weaknesses, and the diagnostic usefulness of a modality depends mainly on the patient's characteristics, the clinical purpose of the imaging evaluation, and the expertise of imaging professionals.

Bile duct dysplasia in the setting of chronic hepatitis C and alcohol cirrhosis

Intrahepatic cholangiocarcinomas are rare and risk factors remain incompletely understood, but one recently identified potential risk factor is chronic hepatitis C (HCV) infection. To further study this potential association, we searched for dysplasia in the intrahepatic bile ducts in native explanted livers in cases of chronic HCV and control groups. Cases of chronic biliary tract disease were excluded. A total of 1058 explants were reviewed: HCV (511), alcohol alone (112), HCV and alcohol (85), HBV (67), cirrhosis from other causes (149), and noncirrhotic livers, for example, cases transplanted for acute liver failure (134). Dysplasia of the intrahepatic bile ducts was seen in 19/1058 (1.8%) of cases and was associated with chronic HCV infection and alcohol use, P=0.01. Ten out of 19 cases of dysplasia were in the setting of chronic HCV, 5/19 were in the setting of alcohol alone, and the remaining 4/19 were in the setting of combined HCV and alcohol. Seventeen out of 19 cases were classified as low-grade dysplasia and 2/19 as high-grade dysplasia. In all cases of dysplasia, the lesions were multifocal and involved septal-sized bile ducts. In 16/19 cases, the dysplasia was papillary whereas in 3/19 cases the dysplasia was flat. In conclusion, dysplasia can be found within the intrahepatic bile ducts in chronic HCV cirrhosis, supporting recent epidemiologic studies identifying chronic HCV as a major risk factor for intrahepatic cholangiocarcinoma. Alcohol also seems to be a risk factor. The dysplastic changes are multifocal, involve septal sized bile ducts, and are typically papillary.

Pedicled greater omentum flap for preventing bile leak in liver transplantation patients with poor biliary tract conditions

BACKGROUND

Bile leak remains a main complication in liver transplantation patients with poor biliary tract conditions, mainly caused by an insufficient blood supply or dysplasia of the biliary tract. Although Roux-en-Y modus operandi can be adopted, the risk of other complications of the biliary tract such as infection increases. Using pedicled greater omentum flaps to wrap the anastomotic stoma, which increases the biliary tract blood supply, may reduce the incidence of bile leak.

METHODS

Fourteen patients undergoing piggy-back liver transplantation and having poor biliary tract conditions were treated with pedicled greater omentum flaps to wrap the anastomotic stoma of the biliary tract. Their clinical data were analyzed retrospectively.

RESULTS

Of the 14 patients, only one (7.1%) had a mild bile leak on the 8th day post-operation and fully recovered after symptomatic treatment. The other patients had no biliary complications.

CONCLUSIONS

Using pedicled greater omentum flaps to wrap the anastomotic stoma of the biliary tract is an effective way to prevent bile leak in liver transplantation patients, especially those with poor biliary tract conditions. However, experience with this surgical technique still needs to be further explored.