Biliary lithiasis and helminthiasis

Gallbladder Mucus Plug Mimicking Ascaris Worm: An Ambiguous Cause of Biliary Colic

Biliary colic is a visceral pain caused by attempts of the gallbladder or bile duct to overcome the obstruction in the cystic duct or ampulla of Vater. Obstruction can be due to different etiologies such as stone, mass, worm, and rarely by mucus plug. We report the case of a 31-year-old gentleman who presented with recurrent biliary colic and weight loss. Work-up showed linear calcifications in the gallbladder extending to the common bile duct suggesting hepatobiliary ascariasis. Further investigations including stool analysis, upper endoscopy, endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) did not support our provisional diagnosis. Laparoscopic cholecystectomy was performed. Histopathological finding was grossly ambiguous; a rope-like mucus plug resembling ascaris worm was noted. The patient's condition improved instantly after the procedure. To our knowledge, we are reporting the first case in the English literature describing this unique entity of symptomatic gallbladder disease to increase awareness and improve its management.

Recurrent pyogenic cholangitis: a review of imaging findings and clinical management

Recurrent pyogenic cholangitis (RPC) is an infective process involving the biliary tree typified by pigmented intraductal calculi with dilatation of the intra- and extrahepatic biliary tree. Previously endemic to South-east Asia, RPC can now be seen in Western countries with the increasing access to international travel and immigration. Affected patients are often plagued by recurrent bouts of cholangitis, and commonly suffer from complications such as abscess formation and biliary strictures. In severe cases, cirrhosis with portal hypertension may develop. The disease is also a known risk factor for cholangiocarcinoma, and can be seen in up to 5% of affected patients. Its exact etiology is unknown, but parasitic infections such as Clonorchis sinensis and Ascaris lumbricoides, ascending bacterial infection with gut flora (Escherichia coli) and low socioeconomic status have been associated strongly with it. This paper reviews the imaging features of the disease, as well as the roles of interventional radiology and surgery with respect to management of the condition.

Oriental cholangiohepatitis masquerading as cholangiocarcinoma: A rare presentation that surgeons need to know

INTRODUCTION

The detection of an abnormal hepatic mass with ductal dilatation is highly concerning for malignancy. However, if such patients happen to be immigrants from endemic parts of Asia or South America, further investigations are necessary to rule out oriental cholangiohepatitis, a rare recurrent disease of the hepatobiliary system that can masquerade as cholangiocarcinoma.

PRESENTATION OF CASE

We report a case of a patient of South Asian origin who presented to us with acute cholangitis and moderately dilated left hepatic ducts. The findings were highly suspicious for advanced hepatic malignancy; however the laboratory and pathological investigations remained normal. We suspected an unlikely etiology and proceeded with conservative hepatic resection. The histology revealed cholangiohepatitis without any evidence of malignancy.

DISCUSSION

Cholangiohepatitis is a complex hepatobiliary disease that commonly manifests as recurrent cholangitis or overt biliary sepsis and can rarely present as an abnormal hepatic mass. It results from the development of intrahepatic or extrahepatic strictures that causes stone formation and biliary dilation in the absence of gallbladder disease. Although it is endemic in many parts of the world, it is rare in the western world, and therefore it can present as a significant diagnostic enigma.

CONCLUSION

Cholangiohepatitis is a rare clinical entity that requires a multi-disciplinary team approach. Surgery plays a dominant role in the management of such patients and therefore surgeons need to be aware of this disease.

Endoscopic management of biliary parasitic diseases

AIM/MATERIALS AND METHODS: Between January 2000 and June 2007, 3,548 endoscopic retrograde cholangiopancreatography (ERCP) were performed for extrahepatic cholestasis, cholangitis, and choledocholithiasis. The results of ERCPs were evaluated retrospectively and examined carefully to investigate the management and endoscopic therapy of biliary parasites.

RESULTS

Of the 3,548 patients who underwent ERCP, 24 (0.66%) were found to have biliary parasitosis. The mean age of the biliary parasitosis patients (16 women) was 48.6 (15-77) years. Of these 24 cases, 16 patients had hydatid cystic disease (eight with partial obstruction of the biliary tract, and eight with ruptured cysts), four patients had Fasciola hepatica, and four patients had Ascaris lumbricoides infestation. Endoscopic sphincterotomy was performed, after which the choledochus was examined carefully by balloon catheter and basket procedure.

CONCLUSION

The ERCP procedure is very useful in the therapy of biliary parasitic infestations.

Sclerosing cholangitis: a focus on secondary causes

Secondary sclerosing cholangitis (SSC) is a disease that is morphologically similar to primary sclerosing cholangitis (PSC) but that originates from a known pathological process. Its clinical and cholangiographic features may mimic PSC, yet its natural history may be more favorable if recognition is prompt and appropriate therapy is introduced. Thus, the diagnosis of PSC requires the exclusion of secondary causes of sclerosing cholangitis and recognition of associated conditions that may potentially imitate its classic cholangiographic features. Well-described causes of SSC include intraductal stone disease, surgical or blunt abdominal trauma, intra-arterial chemotherapy, and recurrent pancreatitis. However, a wide variety of other associations have been reported recently, including autoimmune pancreatitis, portal biliopathy, eosinophillic and/or mast cell cholangitis, hepatic inflammatory pseudotumor, recurrent pyogenic cholangitis, primary immune deficiency, and AIDS-related cholangiopathy. This article offers a comprehensive review of SSC.

Proteomic analysis of livers of patients with primary hepatolithiasis

Primary hepatolithiasis or intrahepatic calculi (IHC), which is characterized by the formation of gallstones in the intrahepatic bile duct, is an intractable liver disease and suspected to be one of the causes of cholangiocellular carcinoma. To obtain an insight into the disease, we performed proteomic analysis of liver tissue specimens of paired affected and unaffected hepatic segments from patients with primary hepatolithiasis by two-dimensional gel electrophoresis followed by identification of proteins. For the specimens from the unaffected segments, 125 spots out of 613 spots were identified, defining 83 unique protein names. For the specimens from the affected segments, 102 spots out of 671 spots were identified, defining 74 unique protein names. To further precisely compare, we used two-dimensional fluorescence difference gel electrophoresis. Consequently we identified 12 up-regulated proteins and 21 down-regulated proteins. The up-regulated proteins contained the proteins related to liver fibrosis and to cellular oxidoreduction. The down-regulated proteins contained RAF kinase inhibitor protein, chaperonin and proteins related to principal liver function.

Relation of hepatolithiasis to helminthic infestation

BACKGROUND AND AIM

The relation of helminthic infestation to hepatolithiasis is a subject of dispute. This case-control study was undertaken to evaluate the prevalence of helminthiasis in hepatolithiasis patients and to compare the clinicopathological features of hepatolithiasis between patients with and without helminthiasis.

METHODS

The prevalence of ascariasis or clonorchiasis was evaluated using ELISA in 131 patients with hepatolithiasis who were treated at Show-Chwan Memorial Hospital and 121 subjects who constituted a control group. The patients' detailed histories and medical charts were reviewed.

RESULTS

The prevalence of positive immunodiagnosis of ascariasis and clonorchiasis was higher in patients with hepatolithiasis than in control subjects (33.6%, 44/131 vs 17.4%, 21/121, odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.28-4.56, P = 0.005; and 6.9%, 9/131 v 0.8%, 1/121, OR = 8.85, 95% CI = 1.12-188.69, P = 0.02). Patients with helminthiasis rarely had concurrent gallbladder stones (26%, 12/47 vs 55%, 46/84, OR = 0.28, 95% CI = 0.12-0.66, P = 0.002). Prior to the diagnosis of hepatolithiasis in adulthood, most of the patients with helminthiasis tended to have a history of recurrent abdominal pain in their childhood and an asymptomatic 'lucid interval' during their teenage years (70.2%, 33/47 vs 39.3%, 33/84, OR = 3.64, 95% CI = 1.59-8.42, P = 0.0005). However, the prevalence of intrahepatic duct stricture (38.3%, 18/47 vs 40.5%, 34/84, OR = 0.91, 95% CI = 0.41-2.02, P > 0.05), secondary biliary cirrhosis (6.4%, 3/47 vs 3.6%, 3/84, OR = 1.84, 95% CI = 0.28-12.03, P > 0.05), cholangiocarcinoma (2.1%, 1/47 vs 0%, 0/84, OR = approximately , P > 0.05), and stone recurrence (54.8%, 24/42 vs 50.0%, 38/76, OR = 1.33, 95% CI = 0.58-3.06, P > 0.05) did not significantly increase.

CONCLUSIONS

Helminthiasis is a possible risk factor for hepatolithiasis, although it is unlikely to increase the incidence of complications, including bile duct stricture, secondary biliary cirrhosis, and cholangiocarcinoma. Patients with helminthiasis tend to have a history of an asymptomatic 'lucid interval' between the periods of recurrent abdominal pain in their childhood and the diagnosis of hepatolithiasis in their adulthood.

Opisthorchiasis-associated biliary stones: Light and scanning electron microscopic study

AIM: Biliary stones are frequently encountered in areas endemic for opisthorchiasis in Thailand. The present study was to describe the prevalence and pathogenesis of these stones.

METHODS: Gallstones and/or common bile duct stones and bile specimens from 113 consecutive cholecystectomies were included. Bile samples, including sludge and/or microcalculi, were examined for Opisthorchisviverrini eggs, calcium and bilirubin. The stones were also processed for scanning electron microscopic (SEM) study.

RESULTS: Of the 113 cases, 82 had pigment stones, while one had cholesterol stones. The other 30 cases had no stones. Most of the stone cases (76%, 63/83) had multiple stones, while the remainder had a single stone. Stones were more frequently observed in females. Bile examination was positive for O.viverrini eggs in 50% of the cases studied. Aggregates of calcium bilirubinate precipitates were observed in all cases with sludge. Deposition of calcium bilirubinate on the eggshell was visualized by special staining. A SEM study demonstrated the presence of the parasite eggs in the stones. Numerous crystals, morphologically consistent with calcium derivatives and cholesterol precipitates, were seen.

CONCLUSION: Northeast Thailand has a high prevalence of pigment stones, as observed at the cholecystectomy, and liver fluke infestation seems involved in the pathogenesis of stone formation.

Clonorchiasis and cholangiocarcinoma: etiologic relationship and imaging diagnosis

Despite a gradual decrease in prevalence, clonorchiasis is still prevalent in East Asia. A large and compelling body of evidence links clonorchiasis and cholangiocarcinoma, although the mechanisms involved are not completely understood. Clonorchiasis induces biliary epithelial hyperplasia and metaplasia, and this could facilitate at least one stage of the carcinogenesis, which is promoting effect. In areas of endemic infection, more clonorchiasis cases are now diagnosed incidentally during radiological examinations such as cholangiography, ultrasonography, and computed tomography. Radiological findings are regarded as pathognomonic for clonorchiasis since they reflect the unique pathological changes of this disorder. These radiological examinations currently play important roles in the diagnosis, staging, and decision-making process involved in the treatment of cholangiocarcinoma. The morphological features and radiological findings of clonorchiasis-associated cholangiocarcinoma are essentially combinations of the findings for the two diseases. The morphological features of clonorchiasis- associated cholangiocarcinoma, observed in radiological examinations, do not differ from those of the usual cholangiocarcinoma. In patients diagnosed with or suspected to have clonorchiasis, radiological findings should be carefully scrutinized for occult cholangiocarcinoma.

Hepatolithiasis with biliary ascariasis--a case report

BACKGROUND

Biliary ascariasis is regarded as possible etiological factor for hepatolithiasis. Here we report one case of a patient with hepatolithiasis with biliary ascariasis who developed a liver abscess, which was treated with partial hepatectomy.

CASE PRESENTATION

A young adult female presented with epigastric pain and vomiting with repeated attacks of cholangitis. ERCP showed evidence of multiple intrahepatic calculi with the development of abscess in the left lobe of liver. The patient underwent partial hepatectomy and was found to have biliary ascariasis on histology. She was treated with antihelmenthic therapy and has had an uneventful postoperative period of 2 years.

CONCLUSION

Biliary ascariasis with hepatolithiasis, although rare, should be considered in endemic countries.

Acute (ascending) cholangitis

Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.

Current Management of Recurrent Pyogenic Cholangitis

Recurrent pyogenic cholangitis (RPC) is a chronic disease with multiple exacerbations requiring repeated biliary dilatation and stone removal. Even after adequate biliary drainage, most patients will have progression of intrahepatic disease. Management of patients with RPC is a multidisciplinary challenge for endoscopists, interventional radiologists, and surgeons because of the frequency and inaccessibility of strictures and stones. Complete stone clearance at any one operation is difficult. Hepaticojejunostomy with a subcutaneous afferent limb is a safe and effective way to provide access to the biliary tree for the management of patients with RPC. In our experience, trans-stomal cholangioscopic stricture dilatation followed by stone removal remains the basis of therapy in patients with RPC. By diligent surveillance, we should be able to eliminate or decrease the number of stones and prevent cholangitis and its sequelae.

Management of hepatobiliary and pancreatic Ascaris infestation in adults after failed medical treatment

BACKGROUND

The roles of endoscopy and surgery in the management of Ascaris lumbricoides affecting the hepatobiliary and pancreatic system in adults were determined.

METHODS

All patients undergoing endoscopic retrograde pancreatography for ascariasis of the biliary or pancreatic system unresponsive to standard medical therapy were analysed. Worms were extracted using snare, Dormia basket or biopsy forceps. Success was defined as clearance of worms and eradication of symptoms.

RESULTS

Endoscopic extraction was performed in 25 patients with success in 19. Failures occurred in one patient with Ascaris in the gallbladder, and in five with associated strictures or stones. All six patients were treated successfully by surgery.

CONCLUSION

Endoscopy was successful in the treatment of Ascaris infestation resistant to medical therapy in 19 of 25 patients. Surgery remains important in the management of infestations complicated by biliary or pancreatic strictures and stones, or worms in the gallbladder.

Serial cholangiographic appearances in recurrent pyogenic cholangitis

From December 1982 to December 1991, cholangiograms were obtained in 227 patients with recurrent pyogenic cholangitis. Cholangiographic abnormalities included biliary dilation, calculi, sludge, excessive branching, and arrowhead formation of intrahepatic ducts and biliary strictures. In 21 patients, previous evidence of biliary ascariasis was seen. Repeat cholangiograms were performed in 55 patients in a follow-up period of 18.0 +/- 1 months. Of these patients, 12 treated conservatively continued to get recurrent cholangitis and revealed worsening abnormalities on repeat cholangiograms. Another 25 patients had successful endoscopic sphincterotomy and extraction of biliary calculi. These patients remained free of symptoms on follow-up, with significant resolution of abnormalities on repeat cholangiograms. The remaining 18 patients with failed surgical or endoscopic interventions continued to get recurrent episodes of cholangitis and worsening of abnormalities on repeat cholangiograms. This retrospective study indicates that the natural course of recurrent pyogenic cholangitis is a progressive, destructive cholangiopathy. Ascaris lumbricoides invasion of the biliary tree is an initiating event in a sub-group of patients.

Intrahepatic biliary stones: imaging features and a possible relationship with ascaris lumbricoides

Intrahepatic (IH) biliary stones are common in East Asia as part of a disease known as Oriental cholangiohepatitis (OCH). At a hospital serving non-Oriental communities, 40 patients were diagnosed on ultrasound (US) during an 8-year period as having IH stones. Follow-up showed that the diagnosis was false in three cases. In the 37 patients with IH stones, 33 conventional retrograde cholangiograms were done; 26 underestimated the IH abnormalities or missed them entirely. Computed tomography (CT) was done in 15 of these 37 patients; the attenuation of the stones was found to be only slightly above that of liver. The evidence that Ascaris lumbricoides was the cause of IH stones in our patients was that: they came mainly from communities in which A. lumbricoides infestation is virtually universal at some stage of childhood, and none from communities in which it is infrequent; their average age was younger than that of patients with conventional gall-stones, fitting with the fact that infestation is predominantly in childhood; A. lumbricoides is the only parasite in our region that invades the biliary system; the histories of the first 12 of the 37 patients had been investigated for intestinal infestation, and were all positive; and 12 of the 37 showed evidence at some time of roundworms or remnants in the biliary system, either within the US appearance of the stones ('bundles' and 'pipes') or separately on US, surgery or duodenoscopy. Biliary strictures, which occur in OCH, were not seen in our patients.

Massive infestation by Ascaris lumbricoides of the biliary tract: report of a successfully treated case

This is a report of a 25 years old black woman from the city of São Paulo, Brazil, who developed acute obstructive cholangitis of Ascaris lumbricoides with septicemia and multiple hepatic abscesses. The patient had sickle cell trait and normal delivery 3 months ago. Massive infestation of the biliary tract by Ascaris lumbricoides was diagnosed by abdominal ultrasonography and endoscopic retrograde cholangiography. Sixty worms were removed from the common bile duct and hepatic abscesses were drained by surgery. The infectious process was polymicrobial. The patient's recovery was complete after a long evolution with a wide spectrum antibiotic therapy. New surgeries were needed to remove residual worms in the biliary tract. The diagnostic methods, clinical-biochemical features and also the clinical and surgical management are presented. The biliary ascariasis pathophysiology is commented.

Clonorchis-associated cholangiocarcinoma: a report of two cases with unusual manifestations

Two cases of Clonorchis-associated cholangiocarcinoma are described along with their cholangiographic features to illustrate the spectrum of pathology ascribed to the injurious effects of the flukes on the bile duct epithelium. This includes adenomatous hyperplasia, extensive fibrosis, and carcinoma. The first case was also complicated by hepatic abscesses, left hepatic lobar atrophy, gastrobiliary and biliarocutaneous fistulae. The second case features an unusually dilated pancreatic duct containing pancreaticoliths that was found later to consist of hyperplastic bile duct epithelium, presumably carried by worm migration in the biliary tree. Liver sections from both patients showed typical features of hepatic clonorchiasis with the cancer. A knowledge of the wide spectrum of clinical presentation of clonorchiasis, particularly cholangiocarcinoma, might aid Western physicians in averting this serious sequela through prompt eradication of the helminthic infection and early recognition and treatment of its complications.

Hepatic abscess

Hepatic abscess--amebic or pyogenic--can be diagnosed with great accuracy by either ultrasonography or computed tomographic (CT) scanning. Ultrasound is the modality of choice and will detect almost 100% of abscesses. Confirmation of a diagnosis of amebic liver abscess is made by the indirect hemagglutination test that should be positive in almost 100% of cases. Cultures of pus from the abscess and from the blood must be obtained in cases of pyogenic liver abscess. A positive culture of pus from the abscess has been achieved in 90% of cases. Ultrasound or CT guidance is utilized in aspiration of a hepatic abscess. In the treatment of an amebic liver abscess, metronidazole is the amebicide of choice. Open drainage is contraindicated. For cases that fail to respond to therapy with amebicides, closed drainage guided by CT or ultrasound is performed. Secondary bacterial infection of an amebic liver abscess is an extremely rare event. The identification and determination of the antibiotic sensitivity of organisms responsible for pyogenic liver abscess is a crucially important step. Unless a celiotomy is necessary to correct an intraabdominal process or the abscess is extremely large, the initial treatment of pyogenic liver abscess is a 2 week course of appropriate antibiotics followed by a 1 month course of oral antibiotics. The majority of pyogenic liver abscesses will respond to such treatment. If drainage of a pyogenic abscess is required, the preferable technique is with a percutaneous CT- or ultrasound-directed catheter.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatobiliary alterations in massive biliary ascariasis. Histopathological aspects of an autopsy case

Hepatobiliary alterations found in an autopsy case of massive Biliary Ascariasis, are reported on histological grounds. Severe cholangitis was the main finding, but other changes were also detected, such as pyloric and intestinal metaplasia, hyperplasia of the epithelial lining, with intraductal papillomas and adenomatous proliferation. Remnants of the worm were observed tightly adhered to the epithelium, forming microscopic intrahepatic calculi. Mucopolysaccharides, especially acid, showed to be strongly positive on the luminal border, and in proliferated glands around the ducts. The authors discuss the similarity between such findings and Oriental Cholangio-hepatitis, and suggest that inflammation and the presence of the parasitic remnants are responsible for the hyperplastic and metaplastic changes, similarly with what occurs in chlonorchiasis, fascioliasis and schistosomiasis.

Oriental cholangitis

Oriental cholangitis is a poorly understood syndrome consisting of intrahepatic pigment stone formation with chronically recurrent exacerbations and remissions. Endemic to Asia, it is being encountered more frequently in the United States due to increased immigration of asians. Twenty-one patients with oriental cholangitis (9 men and 12 women), 19 to 84 years of age, all of whom immigrated from asian countries, were treated between 1970 and 1983. All had histories of episodic abdominal pain, most with jaundice, chills, and fever. Laboratory results were nonspecific but frequently included leukocytosis and hyperbilirubinemia. All patients were operated on with 15 having cholecystectomy, common duct exploration, and a bilioenteric anastomosis. E. coli was cultured from specimens obtained from the biliary tracts of all patients, and 13 patients had more than one organism. Four patients had a previous history of parasitic infection, and four different patients had parasites identified in the biliary tract intraoperatively. Early recognition and appropriate operation will decrease morbidity and mortality.