Malignant versus benign hepatic masses in patients with recurrent pyogenic cholangitis: MR differential diagnosis

PURPOSE

To assess MR findings and diagnostic performance for differentiating malignant from benign hepatic masses in recurrent pyogenic cholangitis (RPC).

MATERIALS AND METHODS

During a recent 6-year period, we performed MRI in 352 patients with RPC. Among them, 58 had confirmed hepatic masses; cholangiocarcinoma (n = 15), abscess (n = 37), inflammatory pseudotumor (n = 3), biloma (n = 3). Two radiologists assessed MR findings including enhancement patterns, intratumoral appearance, peritumoral changes, mass location, and multiplicity. They also graded the malignancy using common MR findings. The receiver operating characteristic analysis and Chi-square test were used. The κ statistics was used to determine interobserver agreement.

RESULTS

The common findings for cholangiocarcinoma were thin and lobulated enhancement at the periphery (n = 8, 53%, P < 0.05); ill-defined enhancement (n = 7, 47%, P < 0.05); slightly high signal on T2 (n = 13, 87%, P < 0.05); mass located in the same lobe of atrophy (n = 11, 73%, P < 0.05) and portal vein thrombosis (n = 15, 100%, P < 0.05). The common findings for benign mass were target-like enhancement (n = 36, 84%, P < 0.05); cluster appearance (n = 15, 35%, P < 0.05); central, fluid-like space (n = 29, 67%, P < 0.05); peritumoral regional high signal on T2 (n = 32, 74%, P < 0.05); multiplicity(n = 21, 49%, P < 0.05). Interobserver agreement was excellent (κ = 0.81-1.000). Area under the curve (Az) for differentiating malignant masses was 0.989, sensitivity was 95.3%, and specificity was 95.3%. There was good interobserver agreement (κ = 0.74).

CONCLUSION

MR imaging is very useful for differential diagnosis of malignant vs. benign hepatic masses in patients with RPC.

Factors involved in resistance to early treatment of acute cholangitis patients

BACKGROUND/AIMS

Severity-based treatment is not homogenously effective for acute cholangitis patients and some are resistant to early treatment. We performed a retrospective cohort study involving acute cholangitis patients and analyzed factors strongly associated with resistance to early treatment.

METHODOLOGY

The subjects were 94 patients admitted to the Department of Gastroenterology, Showa University Hospital and diagnosed with acute cholangitis. The endpoint was set as the presence or absence of resistance to early treatment. Background and blood test results of the patients immediately after admission were surveyed and significant factors independently contributing to resistance to early treatment were extracted from the surveyed factors employing a logistic regression model.

RESULTS

The mean age of the patients was 73.2 ± 11.6 years and 58 were male (61.7%). Jaundice, fever and abdominal pain were observed in 46 (48.9%), 66 (70.2%) and 85 patients (90.4%), respectively. Twenty-eight patients (29.8%) were resistant to early treatment. On multivariate analysis, 3 factors (fever, serum amylase level and systolic blood pressure (below 100 mm Hg)) were extracted as significant factors independently contributing to resistance to early treatment (p<0.05).

CONCLUSIONS

If such resistance can be predicted before treatment, appropriate treatment may be selected to shorten the persistence of symptoms, improving the patient's QOL.

[Giant asymptomatic borderline ovarian tumor in a patient suffering from choledocholithiasis and cholangitis]

Borderline tumors account for about 15% of all ovarian epithelial tumors and are usually diagnosed only when they reach a significant size causing abdominal pain or distension. Clinical, sonographic and Doppler examinations, as well as tumor marker levels cannot detect this type of ovarian tumor with certainty. The definitive diagnosis can only be established by a histopathological examination. We present a case of a 58-year-old patient operated on at our clinic for asymptomatic borderline ovarian tumor. Prior to admission, the patient underwent a medical check-up at the surgery department, where she was diagnosed with choledocholithiasis, and, consequently, the need for urgent surgical treatment for calculosis was excluded. In the presented case the ovarian tumor was revealed owing to the occurrence of choledocholithiasis and cholangitis. The choledocholithiasis and cholangitis, which contributed to the accurate diagnosis of the tumor, were at the same time some of the possible reasons for misleading diagnosis and therapy complications in our patient's case.

[The method of biliary tracts drainage of patients with biliodigestive anastomosis at obstructive jaundice and acute cholangitis]

The internal draining of biliary tracts of patients with obstructive jaundice and acute cholangitis is considered most acceptable, but deficiency of this method is anastomosis failure, stricture and purulent-septic complications hazard. The investigations performed on 79 patients with obstructive jaundice, 36 of which were included in control group, 43 - in main group. To patients of main group with internal draining intraoperatively through the nose and biliodigestive anastomosis into the biliary tract transmitted tube with quartz optical monofiber for endocholedocheal laser irradiation in one lumen and hollow other, serve for drainage and irrigation of bile-excreting way with ozonized physiological solution. The application of endocholedocheal laser radiation and ozonetherapy in combination with suggested at biliodigestive anastomosis biliary tract drainage method allowed to earlier elimination of inflammatory process biliary tract, correct the bile lipids per oxidations disturbances and elevate activity of antioxidant protection system, to reduced the time of patients stay at hospital after surgery period from 20,3±1,24 day in control group to 12,7±0,653 day in main group (p<0,001), to prevent purulent-septic and scarry complications in complex treatment of patients with obstructive jaundice and acute cholangitis.

Obstructive jaundice caused by a portal cavernoma

A 69-year-old Japanese man was admitted to our hospital because of acute cholangitis with biliary obstruction. The cause of obstruction was either compression by a portal cavernoma or cavernous transformation. Multidetector row computed tomography (MDCT) and abdominal ultrasonography (US) revealed a portal cavernoma around the common bile duct. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiography (ERC) demonstrated characteristic short, smooth narrowing of the bile duct. Endoscopic US and intraductal US demonstrated collateral vessels around the bile duct and were helpful for ruling out a neoplastic lesion. Thus, a combination of imaging modalities was useful for diagnosing this hepatobiliary complication, portal biliopathy.

[A case of portal vein thrombosis complicating acute cholangitis treated successfully with danaparoid sodium]

An 81-year-old woman was referred to our hospital with a diagnosis of acute cholangitis. Endoscopic retrograde cholangiography revealed a common bile duct (CBD) stone. In addition, CT showed thrombus of the right portal vein. Endoscopic sphincterotomy was performed to remove the CBD stone. Thrombosis was treated successfully with danaparoid sodium. It was speculated that the treatment of the acute cholangitis induced thrombolysis by the auto-fibrinolysis system and danaparoid sodium prevented the development of thrombus formation in this case.

[A case of hepatocellular carcinoma complicated with Caroli's disease]

A 29-year-old man was admitted with right hypochondralgia and fever. Markedly dilated bile ducts were observed, mainly in the right lobe of the liver. Based on both the clinical findings and imaging, we diagnosed Caroli's disease and choledochal cyst complicated with cholangitis. Hepatocellular carcinoma (HCC) was also observed in segment 3, and the tumor measured 4cm in diameter. The patient was successfully treated with hepatectomy of the right lobe, partial hepatectomy of the left lateral lobe, and bile duct reconstruction. A histopathological examination revealed moderately differentiated HCC without any components of cholangiocellular carcinoma (CCC). Although Caroli's disease is complicated with CCC, a case of Caroli's disease complicated with HCC, as in the present case, is quite rare and therefore is considered to be worthy of reporting.

Clostridium perfringens septicaemia with massive intravascular haemolysis: a case report and review of the literature

We describe the case of a 74-year-old man with cholangitis, complicated by Clostridium perfringens septicaemia and massive intravascular haemolysis. Clostridium perfringens septicaemia is a rare but well-known cause of massive intravascular haemolysis. Here we review 40 similar cases published since 1990. Most cases involve immunocompromised patients with underlying haematological disorder (22.5%), pancreatic or gastric cancer (12.5%) and÷or diabetes (30.0%). Focus of infection is mostly hepatobiliary (45.0%), intestinal or gynaecological after invasive procedure. Eighty percent of reviewed cases did not survive; the median time between admission and death was only eight hours. If an attempt was made to remove the focus of infection (i.e. by drainage of liver abscess, cholecystectomy, hysterectomy or ERCP), this proved to be a strong prognostic indicator of survival. However, in many of the cases the patient had already gone into shock or died before a diagnosis could be made. In severely ill patients with fever and haemolysis on the emergency department Clostridium perfringens septicaemia should always be considered, since early antibiotic treatment and if possible removal of the focus of infection can rescue patients from an otherwise fatal outcome.

Therapy response and outcome of overlap syndromes: autoimmune hepatitis and primary biliary cirrhosis compared to autoimmune hepatitis and autoimmune cholangitis

BACKGROUND/AIMS

We have assessed two different overlap syndrome groups in patients with AIH-PBC and AIH-AIC, with respect to therapy response and outcome.

METHODOLOGY

In this retrospective, non-randomized study, a total of 22 overlap cases were collected, 12 of those had a simultaneous form of AIH-PBC and 10 of those with AIH-AIC. Two groups were compared in terms of clinical, biochemical, immunological, histological features and response to treatment. The mean follow-up time was 31.7 +/- 11.0 mo in AIH-PBC and 41.1 +/- 29.6 mo in AIH-AIC, respectively.

RESULTS

The clinical and laboratory characteristics at presentation were not significantly different between the two groups, except a higher serum IgM level and lower AIH score in AIH-PBC group compared to AIH-AIC group (p < 0.05). First-line treatment was UDCA alone in 3 of AIH-PBC group and combination of UDCA and immunsuppressives in the remaining AIH-PBC (n = 9) and in all of the AIH-AIC (n = 10). During follow-up, only one of 10 patients in IIH-AIC group, but six of 12 patients in AIH-PBC group progressed to liver failure. So, complete remission was significantly higher in the AIH-AIC than in the AIH-PBC group ( % 90 vs % 50, p = 0.045).

CONCLUSION

To our results, in cases of AIH-PBC/AIC overlap, patients with high AIH score and negative AMA should be treated with combined therapy of corticosteroids and UDCA. However, patients with low AIH score and positive AMA should use UDCA firstly, if no response, the addition of corticosteroids should be considered with close monitoring. In this cohort, the prognosis of AIH-PBC overlap was much worse than that of AIH-AIC.

Skin fragility syndrome in a cat with cholangiohepatitis and hepatic lipidosis

A case of acquired skin fragility syndrome associated with hepatic disease in a 9-year-old, spayed female, domestic shorthair cat is described. The cat was admitted to the veterinary hospital of the University of São Paulo (Brazil) with a 6-week history of vomiting, inappetence and weight loss. Remarkable signs were weakness, lethargy and profound jaundice that had been present for 10 days according to the owner. On completion of the physical examination, when the cat was gently manipulated for blood collection the thoracic limb and interscapular skin tore. Liver enzymes and bilirubin levels were all above the normal range. On histological examination of skin and liver, Masson's trichrome stain showed collagen fibre alteration and major hepatocyte abnormalities. Findings were consistent with feline skin fragility syndrome associated with cholangiohepatitis and hepatic lipidosis.

[Role and indications of ERCP in treatment of acute biliary pancreatitis]

Results of endoscopic treatment of patients with biliary acute pancreatitis are presented. Initially this form of treatment was rather performed in the late period of the disease. After publication of the controlled randomized study by Neoptolemos and Carr-Locke'a, this method of the treatment was recommended in the early phase of the disease within the first 72 hours after hospital admission and only in patients with severe acute biliary pancreatitis. Recently, meta-analysis of controlled randomized studies restricted indications of this procedure only in patients with associated with acute cholangitis.

[A program for evaluation of severity of biliary sepsis and a choice for therapeutic and diagnostic methods]

The program of actions for the assessment of severity of biliar sepsis and the choice of algorithms for relevant medical-diagnostic measures is presented. The account is taken of the traumatic factor of operation, the method of narcosis (endotracheal, local anaesthesia) and severity of the initial condition in individual patients. It is suggested to use this program in the form of computer software for the diagnosis of severity of the disease in septic patients, creation of the database and electron archives of the results of the treatment for the purpose of continuous monitoring the patients' conditions.

[Expression of human triggering receptor expressed on myeloid cells 1 in peripheral blood mononuclear cells of patients with acute obstructive suppurative cholangitis]

OBJECTIVE

To investigate the expression pattern of human triggering receptor expressed on myeloid cells 1 (TREM-1) mRNA in peripheral blood mononuclear cells and its clinical significance in acute obstructive suppurative cholangitis (AOSC).

METHODS

Peripheral blood mononuclear cells were collected from 36 patients with AOSC and 40 healthy adults. TREM-1 mRNA was determined by semi-quantitative RT-PCR, and TREM-1 protein by immunocytochemistry. Enzyme-linked immunosorbent assay (TNF-alpha) was used to detect the level of tumor necrosis factor-alpha (TNF-alpha), and immunoturbidimetry employed to detect C reactive protein.

RESULTS

The expression of TREM-1 mRNA relative to beta-actin was 1.007-/+0.252 in patients with AOSC, significantly higher than that in the healthy adults (0.457-/+0.053, P<0.05). The two groups also showed significantly different TREM protein expression (P<0.01). The AOSC patients exhibited significantly higher levels of TNF-alpha and C reactive protein than the healthy adults (P<0.01).

CONCLUSION

The expression of human TREM-1 in peripheral blood mononuclear cells is up-regulated obviously in early stage of AOSC, probably suggesting an important role of TREM-1 in the development of AOSC.

Primary sclerosing cholangitis associated with fibrosis of the submandibular glands and the pancreas

A new syndrome of primary sclerosing cholangitis associated with fibrosis of the submandibular glands and the pancreas is described in a 43-year-old male. The sclerosing cholangitis was diagnosed at laparotomy because of cholestasis and the fibrosis of the submandibular glands and pancreas confirmed at microscopical investigation of biopsy specimens. The cholangitis responded well to treatment with a low dose of prednisolone (7.5--10 mg) and an endoscopic retrograde cholangiopancreaticographic examination 10 months after the operation revealed normal bile ducts.

Abscess of the round ligament of the liver associated with acute obstructive cholangitis and septic thrombosis

A man with abscess of the round ligament of the liver associated with acute obstructive suppurative cholangitis and portal thrombosis is reported. A 63-year-old man was admitted with epigastralgia and high fever. Blood tests showed elevation of hepato-biliary enzymes and coagulopathy consistent with acute obstructive suppurative cholangitis and disseminated intravascular coagulation. Computed tomography revealed a small abscess of the round ligament of the liver and left portal thrombosis. After endoscopic biliary stenting, antibiotics and thrombolytic therapy, the high fever, disseminated intravascular coagulation and portal thrombosis rapidly improved, and the round ligament abscess was also later resolved.

[Surgery for gallstone disease in two time periods]

BACKGROUND

Laparoscopic cholecystectomy was introduced at our institution in October 1990. The perioperative results from 1.1.1991 to 31.12.1995 (first period) are compared with those from 1.1.2001 to 31.12.2005 (second period).

MATERIAL AND METHODS

All patients who had undergone surgical treatment for gallstone disease at Asker and Baerum Hospital in the first or second period were included. Data retrieval was partly prospective and partly retrospective in both periods.

RESULTS

Significantly more patients underwent cholecystectomy in the second than in the first period (843 vs. 342), but the proportion of patients that were operated on an acute indication was lower in the second (91 of 843) than in the first (79 of 342) period, p < 0.001. This coincided with a decline in the number of cholecystectomy patients with complications to gallstone disease (pancreatitis, cholangitis or acute cholecystitis) and a significant reduction of operating time and duration of hospital stay after the operation, whereas the number of per- and postoperative complications remained unchanged.

INTERPRETATION

The number of patients operated for gallstone disease during the first 15 years of laparoscopic surgery has increased significantly. Fewer patients with acute cholecystitis are treated surgically, and the proportion of patients suffering from pancreatitis, cholangitis or acute cholecystitis before surgery appears to have declined.

Considerations concerning laparoscopic cholecystectomy in the extremely elderly

BACKGROUND

Since octogenarians become a growing part of the population and surgical care is possible in them, this study was conducted to evaluate the outcome of laparoscopic cholecystectomy in patients 80 years of age and over.

METHODS

From June 1993 to May 2006, a total of 1263 patients underwent a laparoscopic cholecystectomy, applying the four-trocar American technique; 21 among them were >/=80 years. We retrospectively reviewed patients' age, gender, indication for surgery, comorbid conditions, American Society of Anesthesiologists (ASA) score, conversion to open procedure, postoperative complications, and length of hospital stay.

RESULTS

The mean age in the >/=80 group was 82.5+/-3 and 57% were women, while in the <80 group 72% of patients were women. Recurrent biliary colic was the most frequent (62%) indication for surgery among the elderly patients. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed preoperatively in 6 elderly patients (29%); there were 4 cases of acute calculus pancreatitis and 2 cases of acute cholangitis. A high surgical risk (ASA score of III and IV) was estimated in 11 patients (52%) from the >/=80 group versus 32% in the <80 group (P =0.047). Conversion rate was higher (19%) and hospital stay was longer (4.9 days) in the >/=80 group, compared to younger patients (P =0.01). Mortality was zero and morbidity was 14% versus 3% in the <80 group (P =0.03), including 1 case of postoperative bleeding, 1 case of wound infection, and 1 case of pulmonary atelectasis, respectively.

CONCLUSIONS

Laparoscopic cholecystectomy in the extremely elderly is safe and well tolerated; however, it is associated with a higher conversion rate, increased morbidity, and a longer hospital stay.

Pancréatite auto-immune

Chronic autoimmune pancreatitis is an entity distinct from all other forms of chronic pancreatitis. It is expressed by signs of acute or chronic pancreatitis, sometimes associated with cholestatic jaundice. In imaging, it may appear as diffuse (duct destructive) or pseudotumoral lesions. These 2 aspects are probably different clinical forms of chronic autoimmune pancreatitis. Some autoimmune diseases are associated with chronic autoimmune pancreatitis, but not consistently. One such disease involves a bile disorder very similar to primary sclerosing cholangitis but responsive to corticosteroid treatment. Pancreatitis may be a sign of intestinal inflammatory diseases (and vice versa): testing for Crohn's disease and ulcerative rectocolitis is justified in patients with idiopathic pancreatitis. Chronic autoimmune pancreatitis must be routinely considered in patients with a pancreatic tumor that is for a clinical, epidemiologic, serologic or imaging reason not completely consistent with pancreatic adenocarcinoma. A short corticosteroid therapy (< 4 weeks) is probably less harmful in a patient with pancreatic adenocarcinoma than pancreatectomy (or chemotherapy) in patients with chronic autoimmune pancreatitis. Diagnosis depends on a body of clinical and radiologic evidence. The diagnostic value of serologic markers and especially of autoantibodies must be clarified in the future.

[Treatment tactics of patients with choledocholithiasis complicated with acute cholangitis]

The results of observation and treatment of 137 patients with choledocholithiasis complicated acute cholangitis are presented. The estimated scale APACHE II is adopted for the state severity of patients with choledocholithiasis and cholangitis sigh determination are examined. With multivariant correlative-regression analysis the most informative factors are determined, its grade estimation are carrying out. Optimal treatment tactics depended from state severity is definited. It permits to improve the treatment results owing to decrease of postoperative complications frequency, duration of patients therapy in hospital.

Acute septicemic melioidosis presenting with acute cholangitis

Melioidosis is a disease prevalent in the tropics, especially in Southeast Asia. The most common clinical presentations are bacteremic pneumonia and abscess formation in various organs. Although a wide variety of disease presentations are reported for melioidosis, acute cholangitis has not been previously reported. Herein, we report a 54-year-old woman who had fever, right upper abdominal pain and jaundice 1 week after a flood caused by a typhoon in southern Taiwan. Acute cholangitis and pneumonia with septic shock caused by Burkholderia pseudomallei were subsequently diagnosed.