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Wisneski AD, Carter J, Nakakura EK, Posselt A, Rogers SJ, Cello JP, Arain M, Kirkwood KS, Hirose K, Stewart L, Corvera CU. Ampullary stenosis and choledocholithiasis post Roux-En-Y gastric bypass: challenges of biliary access and intervention. HPB (Oxford) 2020; 22:1496-1503. [PMID: 32340857 DOI: 10.1016/j.hpb.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/13/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ampullary stenosis following Roux-en-Y gastric bypass (RYGB) is increasingly encountered. We describe cases of biliary obstruction from ampullary stenosis and choledocholithiasis to illustrate the associated diagnostic and interventional challenges with this condition. METHODS We reviewed medical records of patients with prior RYGB who underwent a biliary access procedure or surgery for non-malignant disease from January 2012-December 2018. RESULTS We identified 15 patients (4 male, 11 female; mean age 53.7 years) who had RYGB on average 11.7 years (range 1-32) years before diagnosis of biliary obstruction. Fourteen patients reported abdominal pain, 5 had nausea/emesis, 12 had elevated liver function tests, and 6 had ascending cholangitis. Mean common bile duct (CBD) diameter at presentation was 16.9 mm (range 4.0-25.0 mm). Operations included 3 transduodenal ampullectomies (2 with biliary bypass), 2 CBD explorations with stone extraction, 1 laparoscopic cholecystectomy alone, 1 Whipple procedure, 1 balloon enteroscopy with sphincterotomy, and 7 transgastric endoscopic retrograde cholangiopancreatography. All ampulla pathology was benign in patients who underwent resection. At follow-up (mean 15.4 months; range 0.23-44.5 months), 12/15 (80%) reported symptom resolution or improvement. DISCUSSION Ampullary stenosis after RYGB presents challenges for diagnostic evaluation and intervention, often requiring multi-disciplinary expertise. The underlying pathology remains to be elucidated.
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Affiliation(s)
- Andrew D Wisneski
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States
| | - Jonathan Carter
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States
| | - Eric K Nakakura
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States
| | - Andrew Posselt
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States
| | - Stanley J Rogers
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States
| | - John P Cello
- University of California San Francisco, Department of Medicine, Division of Gastroenterology, 513 Parnassus Avenue, S-357, San Francisco, CA, 94143-0538, United States
| | - Mustafa Arain
- University of California San Francisco, Department of Medicine, Division of Gastroenterology, 513 Parnassus Avenue, S-357, San Francisco, CA, 94143-0538, United States
| | - Kimberly S Kirkwood
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States
| | - Kenzo Hirose
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States
| | - Lygia Stewart
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States; San Francisco Veterans Affairs Medical Center, Department of Surgery, 4150 Clement Street, Box 112, San Francisco, CA, 94121, United States
| | - Carlos U Corvera
- University of California San Francisco, Department of Surgery, 513 Parnassus Avenue S-321, San Francisco, CA, 94143-0470, United States; San Francisco Veterans Affairs Medical Center, Department of Surgery, 4150 Clement Street, Box 112, San Francisco, CA, 94121, United States.
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Clinical Characteristics of Concomitant Systemic Lupus Erythematosus and Primary Biliary Cirrhosis: A Literature Review. J Immunol Res 2015; 2015:713728. [PMID: 26090497 PMCID: PMC4452083 DOI: 10.1155/2015/713728] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 01/17/2015] [Indexed: 12/14/2022] Open
Abstract
Although autoimmune diseases often coexist, concomitant cases of systemic lupus erythematosus (SLE) and primary biliary cirrhosis (PBC) are uncommon. In this review paper, 34 cases of SLE with concomitant PBC found in English and Japanese scientific literature and Japanese proceedings were reviewed and summarized, including cases with liver dysfunction complicated by SLE. Of the 34 reported concomitant cases of SLE and PBC, 97.1% (33/34) were females, and PBC was diagnosed initially in 69.0% (20/29), except for five cases in which both SLE and PBC were simultaneously diagnosed. Sjögren's syndrome was the most common autoimmune disease complicating concomitant SLE and PBC (23.5%, 8/34). Five deaths have been reported: two elderly patients died of liver failure because of the worsening of PBC, and another two patients died from pulmonary infection associated with SLE pharmacotherapy. It is uncertain whether concomitant cases occur by chance or share a common immunological or genetic basis.
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Picceli VF, Skare TL, Nisihara R, Kotze L, Messias-Reason I, Utiyama SRR. Spectrum of autoantibodies for gastrointestinal autoimmune diseases in systemic lupus erythematosus patients. Lupus 2013; 22:1150-5. [DOI: 10.1177/0961203313503911] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Organ-specific autoimmune diseases may appear in patients with systemic lupus erythematosus (SLE). Gastrointestinal symptoms are well documented in SLE and may be similar to those related to autoimmune gastrointestinal diseases. Objective Our aim was to search for gastrointestinal organ-specific autoantibodies in 194 patients with systemic lupus and 103 healthy controls from Southern Brazil. Methods Anti-endomysium antibodies (IgA-EmA), anti-gastric parietal cells (GPC) antibodies, anti-smooth muscle antibodies (ASMA), anti-mitochondrial antibodies (AMA) and anti-LKM-1 (liver-kidney microsomal) were searched for using indirect immunofluorescence in the sera of patients and controls. Results The total positivity of antibodies in SLE patients was 14.4% (28/194) and differed significantly from healthy individuals (0.97%; p < 0.001). IgA-EmA was more common in lupus patients than in controls (11/194; p = 0.009), and one of these patients had dermatitis herpetiformis. Clinical association revealed that IgA-EmA was more common in SLE patients with discoid lesions. The frequency of anti-GPC ( p = 0.10), ASMA ( p = 0.16) and AMA ( p = 0.55) did not differ significantly between groups. No patient presented LKM-1 autoantibodies. One patient presenting anti-GPC was diagnosed with atrophic gastritis and pernicious anemia. Conclusion Only IgA-EmA was significantly associated with lupus and with the presence of discoid lesions. Until now, no obvious association with celiac disease has been found.
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Affiliation(s)
- VF Picceli
- Immunopathology Laboratory, Clinical Hospital, Federal University of Paraná, Brazil
| | - TL Skare
- Rheumatology Unit, Hospital Universitário Evangélico de Curitiba, Brazil
| | | | - L Kotze
- Gastroenterology Service, Pontifical Catholic University of Paraná, Curitiba, Paraná, Brazil
| | - I Messias-Reason
- Immunopathology Laboratory, Clinical Hospital, Federal University of Paraná, Brazil
| | - SRR Utiyama
- Immunopathology Laboratory, Clinical Hospital, Federal University of Paraná, Brazil
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Noble-Jamieson G, Jayne D, Hook E. Auto-immune cholangiopathy in a juvenile patient with systemic lupus erythematosus. Acta Paediatr 2012; 101:e262-4. [PMID: 22277082 DOI: 10.1111/j.1651-2227.2012.02611.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Systemic lupus erythematosus (SLE) is a multi-system inflammatory disease characterized by the presence of auto-antibodies. Liver enzyme abnormalities are common but clinical liver dysfunction with jaundice is rare. We report a juvenile female patient with SLE who developed jaundice 9 months after her initial presentation. Further investigations including liver biopsy and magnetic resonance cholangio-pancreatography revealed two likely pathologies for her liver dysfunction; amoxicillin-clavulanic acid induced cholestasis and auto-immune cholangiopathy. The hyperbilirubinaemia resolved spontaneously 3 months after exposure to amoxicillin-clavulanic acid; however, the elevation in Alanine transaminase and Gamma-glutamyl transpeptidase persisted until intensive immunosuppressive therapy achieved complete remission. CONCLUSION We report a rare case of a juvenile patient with SLE and auto-immune cholangiopathy. The use of cholangio-pancreatography as part of the diagnostic work-up achieved the final diagnosis.
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Affiliation(s)
- Gabriele Noble-Jamieson
- Departments of Paediatric Gastroenterology, Hepatology & Nutrition, Adult Renal Medicine and Histopathology at Addenbrookes NHS Trust, Cambridge University Hospitals, UK.
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Schiavon LL, Carvalho-Filho RJ, Narciso-Schiavon JL, Lanzoni VP, Ferraz MLG, Silva AEB. Late-onset systemic lupus erythematosus-associated liver disease. Rheumatol Int 2010; 32:2917-20. [PMID: 20376663 DOI: 10.1007/s00296-010-1492-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Accepted: 03/27/2010] [Indexed: 01/12/2023]
Abstract
Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, which predominantly affects women under 50 years old. Although liver disease is not included in the diagnostic criteria, abnormal liver tests are common among patients with SLE and, in a significant proportion of those patients, no other underlying condition can be identified. We described a case of liver involvement in late-onset SLE presenting with a predominantly cholestatic pattern. Other conditions associated with abnormal liver tests were excluded, and the patient showed a prompt response to steroid therapy. The spectrum of the liver involvement in SLE is discussed, with emphasis on the differential diagnosis with autoimmune hepatitis.
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Affiliation(s)
- Leonardo L Schiavon
- Division of Gastroenterology, Hepatitis Section, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Murdaca G, Colombo BM, Sprecacenere B, Caiti M, Massa G, Picciotto A, Ceppa P, Puppo F. Autoimmune intrahepatic cholangiopathy associated with antiphospholipid antibody syndrome. Eur J Gastroenterol Hepatol 2007; 19:910-2. [PMID: 17873618 DOI: 10.1097/meg.0b013e32820a0035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We report the case of a 26-year-old woman who developed thrombophlebitis in her left leg in 2002, followed by fever, asthenia and headache in 2004. Antinuclear antibodies, antimitochondrial antibodies, anti-liver kidney microsome, anti-Smith, antiphospholipid (aPL) and antineutrophil cytoplasmic antibodies, as well as lupus- anticoagulant activity were positive. Systemic lupus erythematosus (SLE) with aPL syndrome was diagnosed and the patient was treated with azathioprine and heparin. Symptoms persisted and itching arose in the following months. The patient was admitted to our department in January 2005 for jaundice and skin rash. Elevated levels of acute phase proteins and cholestasis and liver necrosis indexes were present. Antinuclear antibodies, aPL and antimitochondrial antibodies (M5) antibodies were positive. Liver histology showed minimal focal hepatocyte necrosis, intrahepatic biliary stasis and intralobular inflammatory cell infiltrate. The absence of clinical signs that are characteristic of SLE as well as the failure to confirm antiSmith antibody positivity led us to rule out a diagnosis of SLE. On the basis of clinical, immunological and histological data, autoimmune intrahepatic cholangiopathy associated with primary aPL syndrome was diagnosed. The patient was treated with intravenous methylprednisolone followed by oral prednisone, warfarin and ursodeoxycholic acid. Liver necrosis and cholestasis indexes rapidly improved within 1 month and progressively reached the normal range. To our knowledge, this is the first description of a patient with an association of intrahepatic cholangiopathy and aPL, thus suggesting that autoimmune liver disease might associate with aPL syndrome.
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Affiliation(s)
- Giuseppe Murdaca
- Department of Internal Medicine, University of Genova, Genova, Italy.
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Mok CC. Investigations and management of gastrointestinal and hepatic manifestations of systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2005; 19:741-66. [PMID: 16150401 DOI: 10.1016/j.berh.2005.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastrointestinal (GI) manifestations of systemic lupus erythematosus (SLE) are protean. Any part of the GI tract and the hepatobiliary system can be involved. Up to two-third of SLE patients develop GI symptoms at some stage of their illnesses. Clinical presentations of GI lupus are non-specific and can be difficult to differentiate from infective, thrombotic, therapy-related and non-SLE etiologies. Clinical acumen and appropriate endoscopic, biopsy and imaging procedures are essential for establishing the correct diagnosis. Acute abdominal pain in SLE patients can herald an intra-abdominal catastrophe and should be evaluated promptly. Surgical intervention should be instituted without delay if conservative management fails or when there is clinical or radiological suspicion of visceral perforation or intra-abdominal collections.
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Affiliation(s)
- C C Mok
- Department of Medicine and Geriatrics, Tuen Mun Hospital, New Territories, Hong Kong, China.
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