Ulcerative colitis and carcinoma of the bile ducts

Risk factors for hilar cholangiocarcinoma: A case-control study in China

AIM: To study the association between hilar cholangiocarcinoma (HC) and pre-existing medical conditions.

METHODS: Three hundred and thirteen HC patients admitted to the Eastern Hepatobiliary Surgery Hospital (Shanghai, China) in 2000-2005 and 608 healthy controls were enrolled in this study. Association between HC and pre-existing medical conditions was studied with their adjusted odds ratio (OR) calculated by logistic regression analysis.

RESULTS: The prevalence of choledocholithiasis (adjusted OR = 2.704, P = 0.039), hepatolithiasis (adjusted OR = 3.278, P = 0.018), cholecystolithiasis (adjusted OR = 4.499, P < 0.0001), cholecystectomy (adjusted OR = 7.012, P = 0.004), biliary ascariasis (adjusted OR = 7.188, P = 0.001), liver fluke (adjusted OR = 10.088, P = 0.042) and liver schistosomiasis (adjusted OR = 9.913, P = 0.001) was higher in HC patients than in healthy controls.

CONCLUSION: Biliary tract stone disease (choledocholithiasis, hepatolithiasis, cholecystolithiasis) and parasitic liver disease (biliary ascariasis, liver fluke, liver schistosomiasis) are the risk factors for HC in Chinese population.

Risk factors for gallbladder cancer: a reappraisal

Carcinoma of the gallbladder has a very unusual geographical distribution with pockets of high incidence seen in Chile, Poland, India, Japan and Israel; it occurs rarely in the rest of the world. It is a common malignancy in the Western Bihar and Eastern Uttar Pradesh regions of India. Patients present with extremes of clinical symptoms, indicating benign biliary diseases on the one hand and incurable malignant disease on the other. Laboratory and roentgenographic data tend to confirm the clinical diagnosis of the advanced incurable disease at presentation, in most cases. Various aetiopathological agents have been proposed but none has stood the test of time. In this article, we have reviewed the aetiopathological agents proposed from time to time over the past two centuries, with special emphasis on the developments made in the last 25 years.

Hepatobiliary and extra-hepatic malignancies in primary sclerosing cholangitis

The increased risk for cholangiocarcinoma in primary sclerosing cholangitis (PSC) is well established, but the factors responsible for the malignant development in the bile ducts in this disease are not known. The pathogenesis of cholangiocarcinoma in PSC including the role of chronic inflammation and oncogenic mutations will be discussed. Cholangiocarcinoma is a leading cause of death in PSC and the prognosis even after liver transplantation is poor, with a median survival after cancer diagnosis of 5 months. Therefore, it is of great importance to identify PSC patients who are at risk of developing cholangiocarcinoma in order to transplant them before cancer has developed.

Hepatobiliary manifestations of inflammatory bowel disease

Several hepatobiliary disorders may be associated with inflammatory bowel disease (IBD). These various disease states can be diagnosed before, concomitant with, or after the diagnosis of IBD is made. This article describes these disorders, clinical features, evaluation, and possible treatment.

Liver transplantation for primary sclerosing cholangitis versus primary biliary cirrhosis: a comparison of complications and outcome

Primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC) are the most common cholestatic disorders in adulthood requiring hepatic transplantation. Although they run similar courses, they may have different problems before and after transplantation. The aim of this study was to compare pre- and post-transplant complications and outcomes in these two similar but distinct patient groups. One hundred and seventeen adult patients underwent liver transplantation at our institution over a 6 year period, including 19 with PSC and 20 with PBC. Pre-transplant there were no significant differences in age, liver biochemistry, haematology or Child-Pugh scores between the two groups. The mean duration of disease before transplant was longer in PSC patients (11.7 vs 6.5 years; P < 0.05). The prevalence of septic cholangitis was greater in PSC (58 vs 5%; P < 0.01) as was the requirement for surgical or radiological interventional procedures, excluding cholecystectomy (53 vs 0%; P < 0.01). At transplantation, four patients with PSC had previously unrecognized cholangiocarcinoma. In the pre-transplant period these four patients had uncontrolled biliary sepsis at the time of transplant vs five of 15 PSC patients without cholangiocarcinoma. Postoperatively, PSC patients had a greater prevalence of intra-abdominal sepsis requiring surgical or radiological intervention (42 vs 5%; P < 0.05). In comparison, patients with PBC had a high prevalence of skeletal complications (30 vs 10%; P < 0.05) particularly avascular necrosis (15 vs 0%). The prevalence of chronic rejection was similar in both groups (15%). Overall survival was higher in PBC patients (85 vs 63%; P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Etiologic and clinical characteristics of peripheral and hilar cholangiocarcinoma

A 20-year experience with 112 patients with cholangiocarcinoma was reviewed with reference to the demographic, etiologic, and clinical features and prognosis in the following two types: peripheral (originating from the intrahepatic small duct radicles) and hilar (originating from the major hepatic ducts at or near the junction of the right and left hepatic ducts). Seventy of the 112 patients were in the hilar group, and 42 were in the peripheral group. Prolonged high alcohol consumption was a prominent feature in both categories (45% and 37%, respectively). Among the women, 35% of those with the peripheral tumor had used oral contraceptive preparations. The major identifiable etiologic factor among the hilar tumors was ulcerative colitis, with or without sclerosing cholangitis, which was documented in 20 of 70 cases (28.6%), with an additional 4 patients having Crohn's disease. The hilar group mainly had obstructive jaundice initially, whereas abdominal pain and weight loss were the predominant symptoms in the peripheral type. Tumor recurrence was frequent in those undergoing resection or transplantation, and none of those undergoing chemotherapy or radiation therapy showed any objective evidence of response. Overall median survival time was poor in both groups at 12 months.

The spectrum of bile duct lesions in end-stage primary sclerosing cholangitis

Tissue from 15 livers with primary sclerosing cholangitis, obtained at transplantation, was examined histologically with respect to: small and medium sized bile duct lesions; large bile duct lesions; fibrosis/cirrhosis; and parenchymal changes. Lesions affecting small and medium-sized bile ducts were quantified by determining the percentage of 20 portal tracts involved. The two characteristic bile duct lesions of primary sclerosing cholangitis, periductal fibrosis and fibro-obliterative scars, were largely confined to medium-sized portal areas. Although present in each case, the number of such lesions varied considerably. Loss of bile ducts was the most conspicuous feature in small portal tracts where the diagnostic duct lesions of primary sclerosing cholangitis were rarely observed. Inflammation, ulceration and cholangiectases of large intrahepatic ducts were common, and appear to be useful additional diagnostic features.

Primary carcinoma of the gallbladder

Seventy-four patients with primary carcinoma of the gallbladder, diagnosed over 18 years from 1969 to 1987, were studied retrospectively. The most common presenting complaint was abdominal pain, followed by jaundice and weight loss. Surgery was performed in 61 patients and of these patients, only two had accurate preoperative diagnosis which was made by ultrasonography. Twelve of the 13 patients who were treated medically had the disease diagnosed at autopsy. One of the 13 patients had the diagnosis of gallbladder cancer by the findings of ultrasonography and abdominal computed tomography (CT) scanning. The resectability of the surgically managed group was 36.1%, and the majority of patients with advanced tumors (82.2%) were deemed unresectable. The most common histologic type was adenocarcinoma. Liver was the organ most commonly invaded (76.5%) by direct extension and/or metastases, followed by regional lymph nodes (52.9%). The overall 5-year survival rate was 5.4%. A high index of suspicion of the disease, intraoperative examination of gallbladder specimen, and earlier, more aggressive surgical treatment may improve patient survival.

Cholangiocarcinoma

The diagnosis of cholangiocarcinoma can now be made with greater rapidity and accuracy. In the clinical setting of obstructive jaundice, a CT scan or sonogram may suggest cholangiocarcinoma if dilated intrahepatic ducts are seen with a nondilated extrahepatic biliary tree. The diagnosis is confirmed by cholangiography, and the tumor is staged by the combination of cholangiography and angiography. If the tumor extensively involves both lobes of the liver or involves the main portal vein or hepatic artery, the lesion is considered unresectable. These patients are best palliated nonoperatively, but they should still have an attempt at a tissue diagnosis, as various other lesions can masquerade as cholangiocarcinoma. In comparison, if the tumor is confined to or is distal to the hepatic duct bifurcation, extends into only one lobe of the liver, or involves only the right or the left portal vein or hepatic artery, the lesion may be resectable, and exploration is indicated. As many as half of all patients explored with curative intent will have a successful resection. Various surgical options are appropriate for patients undergoing tumor resection, depending on the site and extent of the lesion. Similarly, several surgical options are possible for palliation in patients with unresectable cholangiocarcinoma. The role of radiotherapy in the management of cholangiocarcinoma is uncertain. Our results, like those of many other retrospective analyses, suggest that radiotherapy prolongs survival after curative resection as well as after palliative stenting. However, further data from randomized studies are necessary to support or refute this impression. Further studies of adjuvant chemotherapy or hormonal therapy will also be necessary to improve patient survival.

Does primary sclerosing cholangitis occurring in association with inflammatory bowel disease differ from that occurring in the absence of inflammatory bowel disease? A study of sixty-six subjects

Primary sclerosing cholangitis often occurs in association with inflammatory bowel disease, particularly ulcerative colitis but also Crohn's disease of the colon either with or without terminal ileal disease. Little data exist as to the effect of inflammatory bowel disease on the presenting symptoms, radiological features, response to liver transplantation, and potential risk of bile duct carcinoma in individuals with primary sclerosing cholangitis. In an effort to answer these questions, 66 patients with primary sclerosing cholangitis were studied. The definitive diagnosis of primary sclerosing cholangitis in each was accomplished using cholangiography, which in each case demonstrated characteristic beading, ectasia and stricturing of the intrahepatic and extrahepatic bile ducts. Inflammatory bowel disease was present in 47 (71.2%) patients. Thirty nine (59.1%) had ulcerative colitis; their mean age was 42.5 +/- 11.6 yr (mean +/- SD), and the male/female ratio was 2.9:1. In addition, eight patients (12.1%) had Crohn's colitis; their mean age was 40.5 +/- 6.5 yr, and the male/female ratio of this group was 1:1. Nineteen patients (28.8%) had primary sclerosing cholangitis without any inflammatory bowel disease; their mean age was 42.0 +/- 12.1 yr, and the male/female ratio in this group was 0.72:1. Seventy-two percent of the patients without inflammatory bowel disease had either jaundice, pruritus or fatigue at presentation compared with 41% of the patients with inflammatory bowel disease (p less than 0.05). In contrast, abnormal liver function tests were more common as the first manifestation of liver disease in the latter group (38% vs. 11%; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Extrahepatic bile duct cancer and smoking, beverage consumption, past medical history, and oral-contraceptive use

Information on potential causal factors in 67 patients with histologically confirmed cancer of the extrahepatic bile ducts was compared with that from 273 patients with other cancers. The control group did not include subjects with tobacco- or alcohol-related cancers. The study subjects were interviewed at 11 large hospitals in eastern Massachusetts and Rhode Island between 1975 and 1979. Among the patients with extrahepatic bile duct cancer, the male-female ratio was 1.5. The use of cigarettes was associated with decreased risk of extrahepatic bile duct cancer. The use of alcohol and coffee was not related to risk of extrahepatic bile duct cancer. Fewer patients than controls reported tea consumption. A statistically significant association between the use of oral contraceptives and extrahepatic bile duct cancer was observed among women under 60 years of age. Patients reported significantly higher frequencies of history of ulcerative colitis or diseases of the gallbladder.

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.

Hepatobiliary carcinoma associated with primary sclerosing cholangitis and chronic ulcerative colitis

Hepatobiliary carcinomas were found in eight patients with chronic ulcerative colitis (CUC) and primary sclerosing cholangitis (large-duct PSC; five cases) or "pericholangitis" (small-duct PSC; three cases). The tumors were extrahepatic in five cases and intrahepatic in two; in one case the neoplasm affected both liver and gallbladder. The tumors in seven patients were glandular and, sometimes, cystic and papillary; in the remaining patient a combined hepatocellular carcinoma and cholangiocarcinoma was found. The latter tumor seemed to arise from regenerative nodules in secondary biliary cirrhosis complicating PSC. The presence of carcinoma in situ in areas of fibrous cholangitis, the multicentric origin of the tumor, the presence of tumor-free large-duct PSC or small-duct PSC (pericholangitis) at a distance from the carcinomatous areas, and the documentation, in some cases, of long-standing inflammatory hepatobiliary disease prior to the discovery of the tumors would seem to confirm the clinical impression that carcinomas may develop in pre-existing PSC. The appearance of hepatobiliary carcinomas in patients with classic PSC and in patients with pericholangitis supports previous evidence indicating that cholangiographically diagnosed large-duct PSC and histologically diagnosed small-duct PSC (pericholangitis) are manifestations of a shared condition that could be named PSC syndrome. The findings of the present study indicate that the PSC syndrome predisposes patients for the development of bile duct carcinoma. Most patients with CUC and bile duct carcinoma seem to have PSC prior to the development of the hepatobiliary tumor.

Adenocarcinoma of the hepatic duct junction. A reappraisal of the histologic criteria of malignancy

The morphologic distinction between benign and malignant sclerotic processes involving the hepatic duct junction may be difficult. To determine reliable histologic criteria of malignancy, the authors reviewed 18 cases of clinically suspected adenocarcinoma of the hepatic duct junction (Klatskin tumor) retrieved from our autopsy and surgical pathology files over the last decade. The lesions were compared histologically to a variety of benign sclerotic biliary duct lesions, including four cases of primary sclerosing cholangitis (PSC) treated surgically over the same time period. A diagnosis of malignancy was confirmed histologically in 16 suspected Klatskin tumors, based on the presence of severe cytologic atypia (13) and/or perineural invasion (15). The tumor patients averaged 59 years of age with a male to female ratio of 2:1. Patients with segmental tumor resection and postoperative radiotherapy have survived as a group 6 months longer (average, 15.7 months) than those treated with drainage procedures alone (average, 9.5 months) (P less than 0.005), but have had extensive postoperative morbidity. In all the surgical specimens, tumor was present at one or more margins of resection. Primary sclerosing cholangitis patients were younger (average, 31 years of age) with a similar male predominance, but with a strong history of inflammatory bowel disease. All are alive up to 6.5 years since disease onset, with comparatively little postoperative morbidity. Two clinically diagnosed Klatskin tumors were not confirmed on histologic review. Both patients are alive at 1 and 3.5 years following onset of disease, having experienced little postoperative morbidity. Data indicate that Klatskin tumors are relatively aggressive malignancies, distinct from more indolent benign sclerotic disease, but occasionally mimicked by it clinically. Malignancy can be diagnosed histologically with adequate tissue sampling, thereby facilitating clinical decisions regarding radiotherapy or other palliative surgical procedures.

Primary carcinoma of the gallbladder associated with chronic inflammatory bowel disease

Patients with chronic inflammatory bowel disease have an increased risk of developing carcinoma of the bile ducts. This risk is highest in those with a long history of colitis and total involvement of the colon. The majority of these biliary tract cancers involve the extrahepatic or intrahepatic bile ducts. Occasionally, however, the gallbladder is the site of origin of the tumour. We report three cases of primary carcinoma of the gallbladder complicating chronic inflammatory bowel disease. In two, there was universal chronic ulcerative colitis and in one, Crohn's ileocolitis.

Bile duct carcinoma associated with chronic ulcerative colitis

Patients with chronic ulcerative colitis are prone to a variety of liver disorders. This case report illustrates development of bile duct carcinoma in a patient with long-standing inactive colitis. The report emphasizes the association of chronic ulcerative colitis with bile duct carcinoma and discusses the radiologic preoperative evaluation of the ulcerative colitis patient who develops jaundice.

Carcinoma of the biliary tree complicating Crohn's disease

A patient with long-standing Crohn's disease who subsequently developed carcinoma of the biliary tree is described. Biliary tract neoplasia may represent another extraintestinal complication of Crohn's disease, but its frequency of association is probably less than that of ulcerative colitis.

Hepatic venous occlusion from carcinoma of bile duct in ulcerative colitis

The illness is described of a 25-year-old man with an 18-year history of ulcerative colitis, who presented with obstructive jaundice due to a carcinoma of the bile duct. Terminally, he developed acute symptomatic hepatic venous occlusion due to extrinsic compression of the ostia of the hepatic veins. This was caused by a large mass of intrahepatic metastatic tumour.

Ulcerative colitis and carcinoma of the proximal bile ducts

In a review of 103 patients with carcinoma of the proximal bile ducts, eight patients were noted to have had ulcerative colitis also. This finding is strongly suggestive of a specific association between the two diseases. In three of the patients, carcinoma developed several years after proctocolectomy. Seven of the eight patients were significantly younger than the median age of the group as a whole, but no other apparent difference was noted between those with ulcerative colitis and the remainder of the group.