Relation of hepatolithiasis to helminthic infestation

Evolution of surgical treatment for hepatolithiasis

Hepatolithiasis is a common disease where stones are located in the intrahepatic bile duct. Hepatolithiasis is a disease with regional characteristics. The complication and postoperative recurrence rates of the disease are high. The intrahepatic cholangiocarcinoma and the incidence of liver cirrhosisare the main causes of death in patients with hepatolithiasis. Thus, it is difficult to treat. The majority of biliary stones are readily removed endoscopically, however complex intrahepatic or large refractory extrahepatic stones often require surgical or percutaneous interventions when standard endoscopic methods fail. At present, the main clinical treatment for hepatolithiasis is surgery, of which there are different methods depending on the patient's condition. With the continuous updates and development of medical technology, the treatment of hepatolithiasis has improved. In this paper, several mainstream surgical methods including partial hepatectomy, choledochojejunostomy, biliary tract exploration and lithotomy, percutaneous transhepatic chledochoscopic lithotripsy and liver transplantation used in the clinic are reviewed for clinicians' reference. Depending on the characteristics of each case, a suitable surgical method is chosen to obtain the best treatment effect.

The risk of hepatobiliary complications in Clonorchis and Opisthorchis infection: A systematic review and meta-analysis

Clonorchis sinensis, Opisthorchis viverrini, and Opisthorchis felineus are the three important liver flukes, infecting approximately 25 million people worldwide. Despite the reporting of the carcinogenesis of these liver flukes, the comprehensive and systematic analysis of the pathogenicity of these parasites in hepatobiliary system is still not sufficient. We conducted a thorough systematic review and search for published articles in MEDLINE, Embase, Cochrane Library, China National Knowledge Infrastructure databases until early 2024. Cohort studies, case-control studies, and cross-sectional studies associated with C. sinensis, O. viverrini, or O. felineus infection were selected. Pooled risk ratio (RR), odds ratio (OR) and their 95 % confidence intervals (95 % CIs) were calculated to assess the risk of hepatobiliary complications due to these liver fluke infections. From a total of 6488 articles, 22 eligible studies and 34,367 participants were included for review. Our results showed C. sinensis, O. viverrini, and O. felineus infections were significantly associated with cholangiocarcinoma, with an overall OR of 4.24 (95 % CI: 3.33-5.39, P < 0.00001) and an overall RR of 10.43 (95 % CI: 2.90-37.47, P = 0.0003). The ORs for the association between cholangiocarcinoma and C. sinensis and O. viverrini infection were 4.49 (95 % CI:3.43-5.87, P < 0.00001) and 3.69 (95 % CI: 2.07-6.55, P < 0.00001) respectively. For the association between cholelithiasis and C. sinensis infection, the OR was 6.46 (95 % CI: 5.15-8.11, P < 0.00001). C. sinensis infection increased the risk of cholecystitis and cirrhosis, with the RR of 21.02 (95 % CI: 17.27-25.58) and an overall RR of 8.77 (95 % CI: 6.79-11.33, P < 0.00001) respectively. C. sinensis infection was also significantly associated with fatty liver, with an overall OR of 2.46 (95 % CI: 1.79-3.37, P < 0.00001). This comprehensive study, reviewing the largest dataset to date, provided an overall risk of hepatobiliary complications due to Clonorchis and Opisthorchis infections, and aids more systematic understanding for the pathogenicity of Opisthorchiidae family parasites.

Hepatolithiasis: Epidemiology, presentation, classification and management of a complex disease

The term hepatolithiasis describes the presence of biliary stones within the intrahepatic bile ducts, above the hilar confluence of the hepatic ducts. The disease is more prevalent in Asia, mainly owing to socioeconomic and dietary factors, as well as the prevalence of biliary parasites. In the last century, owing to migration, its global incidence has increased. The main pathophysiological mechanisms involve cholangitis, bile infection and biliary strictures, creating a self-sustaining cycle that perpetuates the disease, frequently characterised by recurrent episodes of bacterial infection referred to as syndrome of "recurrent pyogenic cholangitis". Furthermore, long-standing hepatolithiasis is a known risk factor for development of intrahepatic cholangiocarcinoma. Various classifications have aimed at providing useful insight of clinically relevant aspects and guidance for treatment. The management of symptomatic patients and those with complications can be complex, and relies upon a multidisciplinary team of hepatologists, endoscopists, interventional radiologists and hepatobiliary surgeons, with the main goal being to offer relief from the clinical presentations and prevent the development of more serious complications. This comprehensive review provides insight on various aspects of hepatolithiasis, with a focus on epidemiology, new evidence on pathophysiology, most important clinical aspects, different classification systems and contemporary management.

Hepatobiliary surgery in Taiwan: The past, present, and future. Part I; biliary surgery

In Taiwan, most surgical services were mainly provided by Japanese or Western surgeons before World War II. Tsuchiya Kunita first reported surgical treatment of gallstone diseases in 1915 in Taiwan. After World War II, experienced Japanese surgeons returned to Japan, and well-trained surgeons moved to Taiwan from different hospitals in Mainland China after 1949. In 1954, Liao had reported surgical gallstone diseases treated by cholecytostomy, cholecystectomy, and cholecystogastrostomy or cholecystoduodenostomy from National Taiwan University Hospital (Formos J Surg. 1954;53:833–4). By using of operative cholangiography, diagnosis and removal of intrahepatic stones could be done through choledochostomy reported first by Lee HC from National Defense Medical Center in 1966 and 1968 (Chin Med J ROC. 1966;13:301–8; Chin Med J ROC. 1968;15:124–34). Wei from the National Taiwan University Hospital reported the first left hepatectomy for treating hepatolithiasis on one patient among his series in 1971 (Formos J Surg. 1971;4:178–96). Treatments of hepatolithiasis were well analyzed by Wen and Lee from Triservice General Hospital and Veterans General Hospital in 1972 (Ann Surg. 1972;175:166–77). Hwang was the first to use choledochofiberscope for removing retained stones since 1974 reported from Show Chwan Memorial Hospital in 1978 (Am J Surg. 1978;139:860–4). The first laparoscopic cholecystectomy was performed by Huang from Taipei Cathay General Hospital in 1990 in Taiwan (J Formos Med Assoc. 1991;90:893–9). Nowadays, Taiwan hepatobiliary surgeons were extensively using either laparoscopic or robotic surgery for treatment of hepatobiliary diseases.

In conclusion, we should never forget the great contributions from many clinics in rural villages hosted by Christian or Catholicism organizations in Taiwan hundred years ago. We should express our appreciations to the history of the evolutions of biliary surgical skills. In Taiwan, a great surgeon today is always standing on the shoulders of our ancient giants, our surgical teachers.

Infections and immunity: associations with obesity and related metabolic disorders

About one-fourth of the global population is either overweight or obese, both of which increase the risk of insulin resistance, cardiovascular diseases, and infections. In obesity, both immune cells and adipocytes produce an excess of pro-inflammatory cytokines that may play a significant role in disease progression. In the recent coronavirus disease 2019 (COVID-19) pandemic, important pathological characteristics such as involvement of the renin-angiotensin-aldosterone system, endothelial injury, and pro-inflammatory cytokine release have been shown to be connected with obesity and associated sequelae such as insulin resistance/type 2 diabetes and hypertension. This pathological connection may explain the severity of COVID-19 in patients with metabolic disorders. Many studies have also reported an association between type 2 diabetes and persistent viral infections. Similarly, diabetes favors the growth of various microorganisms including protozoal pathogens as well as opportunistic bacteria and fungi. Furthermore, diabetes is a risk factor for a number of prion-like diseases. There is also an interesting relationship between helminths and type 2 diabetes; helminthiasis may reduce the pro-inflammatory state, but is also associated with type 2 diabetes or even neoplastic processes. Several studies have also documented altered circulating levels of neutrophils, lymphocytes, and monocytes in obesity, which likely modifies vaccine effectiveness. Timely monitoring of inflammatory markers (e.g., C-reactive protein) and energy homeostasis markers (e.g., leptin) could be helpful in preventing many obesity-related diseases.

Imaging Features of Premalignant Biliary Lesions and Predisposing Conditions with Pathologic Correlation

Biliary malignancies include those arising from the intrahepatic and extrahepatic bile ducts as well as the gallbladder and hepatopancreatic ampulla of Vater. The majority of intrahepatic and extrahepatic malignancies are cholangiocarcinomas (CCAs). They arise owing to a complex interplay between the patient-specific genetic background and multiple risk factors and may occur in the liver (intrahepatic CCA), hilum (perihilar CCA), or extrahepatic bile ducts (distal CCA). Biliary-type adenocarcinoma constitutes the most common histologic type of ampullary and gallbladder malignancies. Its prognosis is poor and surgical resection is considered curative, so early detection is key, with multimodality imaging playing a central role in making the diagnosis. There are several risk factors for biliary malignancy as well as predisposing conditions that increase the risk; this review highlights the pertinent imaging features of these entities with histopathologic correlation. The predisposing factors are broken down into three major categories: (a) congenital malformations such as choledochal cyst and pancreaticobiliary maljunction; (b) infectious or inflammatory conditions such as parasitic infections, hepatolithiasis, primary sclerosing cholangitis, and porcelain gallbladder; and (c) preinvasive epithelial neoplasms such as biliary intraepithelial neoplasm, intraductal papillary neoplasm of the bile duct, intra-ampullary papillary tubular neoplasm, and intracholecystic papillary neoplasm of the gallbladder. Recognizing the baseline features of these premalignant biliary entities and changes in their appearance over time that indicate the advent of malignancy in high-risk patients can lead to early diagnosis and potentially curative management. An invited commentary by Volpacchio is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

An Insight into Cholangiocarcinoma and Recent Advances in its Treatment

BACKGROUND

Cholangiocarcinoma (CCA) is a malignant disease of the epithelial cells of the intrahepatic and extrahepatic bile ducts. This review focuses on various aspects of cholangiocarcinoma such as its associated causes, treatment criteria, and more.

METHODS

Although it remains a rare malignancy and is the second most common primary malignancy of the liver, the incidence is increasing, especially the incidence of intrahepatic CCA. Several studies suggested that surgery is not only solution; recently, reported targeted drugs may have the potential to become an alternative option.

RESULTS

This review provides an overview of the current scenario of targeted therapies for CCA, which were tabulated with their current status and it also included its associated causes and its treatment criteria.

CONCLUSION

Because of its rarity and complexity, surgery remains the preferred treatment in resectable patients. Howerver, the studies suggested that the recently reported drugs may have the potential to be an alternative option for the treatment of CCA and related complications. In addition, this review will certainly benefit the community and researcher for further investigation.

Oriental Cholangiohepatitis in a Caucasian male

Recurrent pyogenic cholangitis (RPC) is a condition found almost exclusively in individuals who lived in Southeast Asia. We report a case of a Caucasian veteran diagnosed with RPC after presenting with a 5-year history of recurrent fevers and abdominal pain 20 years after serving in Japan, South Korea, and Guam. Extensive evaluation led to the diagnosis of RPC with improvement after biliary decompression and antibiotics. Although rare, RPC should be considered in individuals who present with recurrent bouts of abdominal pain and fevers regardless of race.

Parasites of the liver - epidemiology, diagnosis and clinical management in the European context

Parasites in the liver cause significant global morbidity and mortality, as they can lead to recurrent cholangitis, cirrhosis, liver failure and cancer. Due to climate change and globalisation, their incidence is increasing, especially in Europe. The correct diagnosis of a hepatic parasite is often delayed because clinicians are unfamiliar with respective entities. Therefore, in this review, we aim to provide clinicians with a comprehensive clinical picture of hepatic parasites and to bring these neglected parasitic liver diseases to the wider attention of hepatology stakeholders in Europe and around the world.

Clinical Characteristics of Clonorchis sinensis-Associated Cholangiocarcinoma: A Large-Scale, Single-Center Study

Background:Clonorchis sinensis (CS) infection is considered a group 1 carcinogen of cholangiocarcinoma (CCA). There were very few studies regarding clinical characteristics of CS-associated CCA (CACC). This study aimed to investigate clinical characteristics of patients with CCA with or without CS infection.

Methods: A total of 367 patients diagnosed with CCA who underwent diagnostic tests for CS infection were enrolled. CS infection was defined as follows: at least one positive serum ELISA test, skin test, stool microscopy, or bile microscopy.

Results: There were 95 (26%) patients with CS infections. The median follow-up duration was 14.9 months (range, 6.07–36.17). The following significant differences were noted among patients with CACC compared to non-CACC; diagnosis at younger age (median 62 years vs. 65 years, p = 0.018), higher male to female ratio (83.2 vs. 61.8%, p < 0.001), and residence in CS-endemic area (46.3 vs. 25.4%, p = 0.014). Univariate analysis of prognostic factors indicated that tumor location, curative resection, tumor stage, and laboratory tests including CA 19-9, CEA, and bilirubin were significantly associated with overall survival, but CS infection was not. In multivariate analysis, tumor location, CEA, curative resection and tumor stage were identified as independent prognostic factors. Among patients under age 64, CACC group had lower survival rate than non-CACC group (p = 0.022).

Conclusions: CACC had the following significant characteristics compared to non-CACC; diagnosis at younger age, higher male to female ratio, higher prevalence in CS endemic areas and poorer overall survival in patients under age 64.

High prevalence of Clonorchis sinensis infections and coinfection with hepatitis virus in riverside villages in northeast China

In China, the prevalence of Clonorchis sinensis (C. sinensis) infections is only evaluated at the provincial level by national sampling surveys, and data from villages and counties are still lacking. In this study, we conducted a cross-sectional survey in 10 villages located along the Lalin River in northeast China. Clonorchiasis was diagnosed using a modified Kato–Katz method that detects the C. sinensis egg in stools. A total of 3,068 persons were screened and 2,911 were recruited for the study. Overall, the prevalence of C. sinensis infection was 29.3%. Among 175 participants who were cured after antiparasitic treatment, 54 (30.86%) were re-infected in this survey. After calibration of potential confounders, male gender, occupation as a farmer, smoking, and occasionally or frequently eating raw fish were independent risk factors for C. sinensis infection. The results of laboratory examinations in the C. sinensis/hepatitis B or C virus co-infection group were similar to those in the hepatitis B or C virus mono-infection groups. In conclusion, C. sinensis is highly endemic in villages along the Lalin River, and the primary route of infection is the consumption of raw freshwater fish. Co-infection with C. sinensis did't aggravate the clinical manifestations of viral hepatitis in this cross-sectional study.

Precursors to Cholangiocarcinoma

Cancers of the biliary tract include intra- and extrahepatic cholangiocarcinomas and gallbladder cancer. Biliary tract cancers are diseases with unfavorable prognoses. In recent years, several lesions have been described as precursors that precede biliary cancers. They include flat and microscopic lesions known as biliary intraepithelial neoplasia, macroscopic and tumor-forming intraductal papillary biliary neoplasia, intraductal tubular neoplasia, and mucinous cystic neoplasm of the bile duct. These conditions are rarely diagnosed, while their natural history and progression to cancer have yet to be adequately characterized. This review examines the epidemiology, pathology, molecular biology, diagnosis, and therapy of these various precursors. Further research is required if we are to better understand this evolving field and improve the prevention and early detection of bile duct cancer.

Large-duct cholangiopathies: aetiology, diagnosis and treatment

Cholangiopathies describe a group of conditions affecting the intrahepatic and extrahepatic biliary tree. Impairment to bile flow and chronic cholestasis cause biliary inflammation, which leads to more permanent damage such as destruction of the small bile ducts (ductopaenia) and biliary cirrhosis. Most cholangiopathies are progressive and cause end-stage liver disease unless the physical obstruction to biliary flow can be reversed. This review considers large-duct cholangiopathies, such as primary sclerosing cholangitis, ischaemic cholangiopathy, portal biliopathy, recurrent pyogenic cholangitis and Caroli disease.

Cholangiocarcinoma: Epidemiology and risk factors

Cholangiocarcinoma (CCA) is a heterogeneous disease arising from a complex interaction between host-specific genetic background and multiple risk factors. Globally, CCA incidence rates exhibit geographical variation, with much higher incidence in parts of the Eastern world compared to the West. These differences are likely to reflect differences in geographical risk factors as well as genetic determinants. Of note, over the past few decades, the incidence rates of CCA appear to change and subtypes of CCA appear to show distinct epidemiological trends. These trends need to be interpreted with caution given the issues of diagnosis, recording and coding of subtypes of CCA. Epidemiological evidences suggest that in general population some risk factors are less frequent but associated with a higher CCA risk, while others are more common but associated with a lower risk. Moreover, while some risk factors are shared by intrahepatic and both extrahepatic forms, others seem more specific for one of the two forms. Currently some pathological conditions have been clearly associated with CCA development, and other conditions are emerging; however, while their impact in increasing CCA risk as single etiological factors has been provided in many studies, less is known when two or more risk factors co-occur in the same patient. Moreover, despite the advancements in the knowledge of CCA aetiology, in Western countries about 50% of cases are still diagnosed without any identifiable risk factor. It is therefore conceivable that other still undefined etiologic factors are responsible for the recent increase of CCA (especially iCCA) incidence worldwide.

A retrospective administrative database analysis of the association between clonorchiasis or helminthiasis and the development of cholelithiasis

PURPOSE

Parasite infestation (PI) is reportedly related to intrahepatic stones (IHSs) and common bile duct (CBD) stones. This study assessed the association of clonorchiasis and helminthiasis with the sub-types of cholelithiasis.

METHODS

The study cohort consisted of 713 patients who were aged ≥20 years with clonorchiasis or helminthiasis for the first time between 2000 and 2010 from the National Health Insurance Research Database. The controls without clonorchiasis and helminthiasis were randomly selected with a 1:1 propensity score matching. All patients were followed up until the end of 2011 to measure the incidence of cholelithiasis.

RESULTS

The risks of cholelithiasis in the clonorchiasis (adjusted hazard ratio [aHR] = 3.72, 95% confidence interval [CI] = 2.01-6.90) and helminthiasis (aHR = 2.27, 95% CI = 1.25-4.16) were higher than in the non-PI cohort. Patients with clonorchiasis had increased risks of gallstones without bile duct stones (aHR = 3.13, 95% CI = 1.54-6.39) and bile duct stones without gallstones (aHR = 4.75, 95% CI = 1.23-18.4). Patients with helminthiasis had an increased risk of gallstones without bile duct stones (aHR = 2.20, 95% CI = 1.11-4.33), but no higher risk of bile duct stones without gallstones was observed in helminthiasis (aHR = 2.22, 95% CI = 0.54-9.06), despite its high aHR. Neither clonorchiasis nor helminthiasis had an increased risk of concomitant gallstones and bile duct stones.

CONCLUSION

Clonorchiasis is related to the development of not only gallstones, but also bile duct stones, and helminthiasis is only associated with the development of gallstones. However, cases of PI are rare in Taiwan, and this requires more international studies to clarify the association between helminthiasis and bile duct stones.

Molecular Pathogenesis of Cholangiocarcinoma

BACKGROUND

Cholangiocarcinomas are a heterogeneous group of malignancies arising from a number of cells of origin along the biliary tree. Although most cases in Western countries are sporadic, large population-based studies have identified a number of risk factors. This review summarises the evidence behind reported risk factors and current understanding of the molecular pathogenesis of cholangiocarcinoma, with a focus on inflammation and cholestasis as the driving forces in cholangiocarcinoma development.

RISK FACTORS FOR CHOLANGIOCARCINOGENESIS

Cholestatic liver diseases (e.g. primary sclerosing cholangitis and fibropolycystic liver diseases), liver cirrhosis, and biliary stone disease all increase the risk of cholangiocarcinoma. Certain bacterial, viral or parasitic infections such as hepatitis B and C and liver flukes also increase cholangiocarcinoma risk. Other risk factors include inflammatory disorders (such as inflammatory bowel disease and chronic pancreatitis), toxins (e.g. alcohol and tobacco), metabolic conditions (diabetes, obesity and non-alcoholic fatty liver disease) and a number of genetic disorders.

MOLECULAR PATHOGENESIS OF CHOLANGIOCARCINOMA

Regardless of aetiology, most risk factors cause chronic inflammation or cholestasis. Chronic inflammation leads to increased exposure of cholangiocytes to the inflammatory mediators interleukin-6, Tumour Necrosis Factor-ɑ, Cyclo-oxygenase-2 and Wnt, resulting in progressive mutations in tumour suppressor genes, proto-oncogenes and DNA mismatch-repair genes. Accumulating bile acids from cholestasis lead to reduced pH, increased apoptosis and activation of ERK1/2, Akt and NF-κB pathways that encourage cell proliferation, migration and survival. Other mediators upregulated in cholangiocarcinoma include Transforming Growth Factor-β, Vascular Endothelial Growth Factor, Hepatocyte Growth Factor and several microRNAs. Increased expression of the cell surface receptor c-Met, the glucose transporter GLUT-1 and the sodium iodide symporter lead to tumour growth, angiogenesis and cell migration. Stromal changes are also observed, resulting in alterations to the extracellular matrix composition and recruitment of fibroblasts and macrophages that create a microenvironment promoting cell survival, invasion and metastasis.

CONCLUSION

Regardless of aetiology, most risk factors for cholangiocarcinoma cause chronic inflammation and/or cholestasis, leading to the activation of common intracellular pathways that result in reactive cell proliferation, genetic/epigenetic mutations and cholangiocarcinogenesis. An understanding of the molecular pathogenesis of cholangiocarcinoma is vital when developing new diagnostic biomarkers and targeted therapies for this disease.

Characterization of intrahepatic cholangiocarcinoma after curative resection: outcome, prognostic factor, and recurrence

Background

Intrahepatic cholangiocarcinoma (ICC) is a relatively rare subtype of cholangiocarcinoma. The study herein gathered experience of surgical treatment for ICC, and aimed to analyze the prognosis of patients who had received curative-intent liver resection.

Methods

A total of 216 patients who had undergone curative-intent liver resection for ICC between January 1977 and December 2014 was retrospectively reviewed.

Results

Overall, the rates of 5-years recurrence-free survival (RFS) and overall survival (OS) were 26.1 and 33.9% respectively. Based on multivariate analysis, four independent adverse prognostic factors including morphology patterns, maximum tumor size > 5 cm, pathological lymph node involvement, and vascular invasion were identified as affecting RFS after curative-intent liver resection for ICC. Among patients with cholangiocarcinoma recurrence, only 27 (16.9%) were able to receive surgical resection for recurrent cholangiocarcinoma that had a significantly better outcome than the remaining patients.

Conclusion

Despite curative resection, the general outcome of patients with ICC is still unsatisfactory because of a high incidence of cholangiocarcinoma recurrence after operation. Tumor factors associated with cholangiocarcinoma remain crucial for the prognosis of patients with ICC after curative liver resection. Moreover, aggressive attitude toward repeat resection for the postoperative recurrent cholangiocarcinoma could provide a favorable outcome for patients.

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.

[Inflammation and Cancer Development in Pancreatic and Biliary Tract Cancer]

Chronic inflammation has been known to be a risk for many kinds of cancers, including pancreatic and biliary tract cancer. Recently, inflammatory process has emerged as a key mediator of cancer development and progression. Many efforts with experimental results have been given to identify the underlying mechanisms that contribute to inflammation-induced tumorigenesis. Diverse inflammatory pathways have been investigated and inhibitors for inflammation-related signaling pathways have been developed for cancer treatment. This review will summarize recent outcomes about this distinctive process in pancreatic and biliary tract cancer. Taking this evidence into consideration, modulation of inflammatory process will provide useful options for pancreatic and biliary tract cancer treatment.

Intrahepatic Duct Stones Harboring Ascariasis Ova: A Case Report

Ascariasis lumbricoides is one of the most common helminthic infestations in humans. Despite the fact that the prevalence of ascariasis in developed countries has been decreasing, biliary ascariasis can cause serious complications, such as acute cholangitis, pancreatitis, and liver abscess. Here we presented a rare ascariasis-related complication-hepatolithiasis.A 60-year-old female patient had symptoms of recurrent cholangitis. Abdominal computed tomography scan revealed left intrahepatic duct stones with left liver lobe atrophy. Endoscopic retrograde cholangiopancreatography was performed, but the stones could not be removed due to left main intrahepatic duct stenosis. The patient was treated with left hemi-hepatectomy. Unexpectedly, Ascaris ova were found on the histopathological examination. She received antihelminthic therapy orally and was on regular follow-up without any complications.Our study indicates that clinicians should be aware of biliary ascariasis in patients with hepatolithiasis, though not living in endemic areas.

Association between Liver Fluke Infection and Hepatobiliary Pathological Changes: A Systematic Review and Meta-Analysis

OBJECTIVE

To provide information about the role of liver fluke infection as a risk factor for hepatobiliary pathological changes and promote awareness among the people living in endemic areas, a systematic review and meta-analysis based on published studies was conducted to examine the association between liver fluke infection and hepatobiliary pathological changes.

METHODS

Relevant original literature was searched in multiple literature databases, including PubMed, Cochrane, Clinical Evidence, Trip Database, Clinical Trials, Current Controlled Trials, Web of Science, the China National Knowledge Infrastructure (CNKI) database, and the Wanfang academic journal full-text database. Studies were selected based on strict screening with inclusion and exclusion criteria. Tests of heterogeneity, sensitivity and publication bias were performed with the Review Manager software, version 5.3, and meta-regression analyses were performed with the Stata software, version 11.0 (Stata Corporation, College Station, TX, USA). Pooled risk ratios (RRs) and odds ratios (ORs) with their 95% confidence intervals (95% CIs) were calculated and used to evaluate the risk of hepatobiliary pathological changes resulting from liver fluke infection. Linear trend analyses were conducted to determine the dose-response relationship using IBM SPSS Statistics 20.0.

RESULT

A total of 36 studies were included in the meta-analysis. Significant associations were found between liver fluke infection and cholangitis or cholecystitis (RR: 7.80, P<0.001; OR: 15.98, P<0.001), cholelithiasis (RR: 2.42, P = 0.03; OR: 4.96, P = 0.03), hepatocellular carcinoma (OR: 4.69, P<0.001) and cholangiocarcinoma (RR: 10.43, P<0.001; OR: 4.37, P<0.001). In addition, heavier infection was significantly associated with higher incidence of hepatobiliary pathological changes (P<0.05). However, cirrhosis was not significantly associated with liver fluke infection (RR: 3.50, P = 0.06; OR: 5.79, P = 0.08). The statistical heterogeneity was significant, no significant difference was observed in the sensitivity analysis, and no publication bias was found.

CONCLUSION

The meta-analysis found that liver fluke infection was significantly associated with cholangitis, cholecystitis, cholelithiasis, hepatocellular carcinoma and cholangiocarcinoma and that more severe infection was associated with higher incidence. However, the association between liver fluke infection and cirrhosis was not significant.

Clinical presentation, risk factors and staging systems of cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary liver tumour. Intra-hepatic CCA develops within the liver parenchyma while extrahepatic CCA involves the biliary tree within the hepatoduodenal ligament. Hilar CCA are also called Klatskin tumour. The CCA incidence has increased worldwide over the last years, but there are also geographic differences, with focus in Asian countries. Known risk factors are primary sclerosing cholangitis (PSC), hepatolithiasis, Caroli's disease, hepatitis B and C infection, liver flukes, cirrhosis, diabetes, obesity, alcohol consumption and probably tobacco smoking. Patients with early CCA have only little discomfort, but can later show episodes with jaundice and other non-specific tumour symptoms. For the staging of the disease different classifications are available, which consider various factors like tumour size, location, regional lymph nodes, metastasis, vascular involvement and tumour marker.

Pathogenesis of cholangiocarcinoma: From genetics to signalling pathways

Cholangiocarcinoma (CCA) is a malignant tumour of bile duct epithelial cells with dismal prognosis and rising incidence. Chronic inflammation resulting from liver fluke infection, hepatitis and other inflammatory bowel diseases is a major contributing factor to cholangiocarcinogenesis, likely through accumulation of serial genetic and epigenetic alterations resulting in aberration of oncogenes and tumour suppressors. Recent studies making use of advances in high-throughput genomics have revealed the genetic landscape of CCA, greatly increasing our understanding of its underlying biology. A series of highly recurrent mutations in genes such as TP53, KRAS, SMAD4, BRAF, MLL3, ARID1A, PBRM1 and BAP1, which are known to be involved in cell cycle control, cell signalling pathways and chromatin dynamics, have led to investigations of their roles, through molecular to mouse modelling studies, in cholangiocarcinogenesis. This review focuses on the landscape genetic alterations in CCA and its functional relevance to the formation and progression of CCA.

Cholangiocarcinoma

Cholangiocarcinoma represents a diverse group of epithelial cancers united by late diagnosis and poor outcomes. Specific diagnostic and therapeutic approaches are undertaken for cholangiocarcinomas of different anatomical locations (intrahepatic, perihilar, and distal). Mixed hepatocellular cholangiocarcinomas have emerged as a distinct subtype of primary liver cancer. Clinicians need to be aware of intrahepatic cholangiocarcinomas arising in cirrhosis and properly assess liver masses in this setting for cholangiocarcinoma. Management of biliary obstruction is obligatory in perihilar cholangiocarcinoma, and advanced cytological tests such as fluorescence in-situ hybridisation for aneusomy are helpful in the diagnosis. Liver transplantation is a curative option for selected patients with perihilar but not with intrahepatic or distal cholangiocarcinoma. International efforts of clinicians and scientists are helping to identify the genetic drivers of cholangiocarcinoma progression, which will unveil early diagnostic markers and direct development of individualised therapies.

Epidemiology and risk factors of biliary tract and primary liver tumors

Primary liver and biliary tract tumors encompass a range of benign and malignant neoplasms. They consist of histologically distinct types of tumors that arise from and are influenced by hepatocytes, biliary epithelial cells, and mesenchymal cells. Improvements in imaging have allowed the detection and diagnosis of these neoplasms to be refined. Investigation at the histologic, molecular, and genetic levels has allowed neoplasms to be categorized and treated. Epidemiology has improved understanding of geographic, ethnic, gender, and cultural differences that link exposures with cancer risk. This article focuses on the epidemiology of major primary adult liver and biliary tract tumors.

Pathogenesis, diagnosis, and management of cholangiocarcinoma

Cholangiocarcinomas (CCAs) are hepatobiliary cancers with features of cholangiocyte differentiation; they can be classified anatomically as intrahepatic CCA (iCCA), perihilar CCA (pCCA), or distal CCA. These subtypes differ not only in their anatomic location, but in epidemiology, origin, etiology, pathogenesis, and treatment. The incidence and mortality of iCCA has been increasing over the past 3 decades, and only a low percentage of patients survive until 5 years after diagnosis. Geographic variations in the incidence of CCA are related to variations in risk factors. Changes in oncogene and inflammatory signaling pathways, as well as genetic and epigenetic alterations and chromosome aberrations, have been shown to contribute to the development of CCA. Furthermore, CCAs are surrounded by a dense stroma that contains many cancer-associated fibroblasts, which promotes their progression. We have gained a better understanding of the imaging characteristics of iCCAs and have developed advanced cytologic techniques to detect pCCAs. Patients with iCCAs usually are treated surgically, whereas liver transplantation after neoadjuvant chemoradiation is an option for a subset of patients with pCCAs. We review recent developments in our understanding of the epidemiology and pathogenesis of CCA, along with advances in classification, diagnosis, and treatment.

Hepatolithiasis after Hepaticojejunostomy: Ascaris lumbricoides in the biliary tract

BACKGROUND

Biliary ascariasis is a common problem in Third World countries and other underdeveloped areas of the world. Ascaris lumbricoides migrates into the biliary tree, where it is apparent commonly on diagnostic imaging. We present a unique case of a patient with chronic right upper quadrant abdominal pain, massive hepatolithiasis, and stricture of a previous hepaticojejunostomy in whom ascariasis was found.

METHODS

A 28-year-old female presented to the emergency department with right upper quadrant abdominal pain, syncope, and seizure-like activity. She was found by magnetic resonance cholangiopancreatography to have cholangitis, choledocholithiasis, and bile duct stricture. After multiple radiographic studies, she was taken to the operating room for revision of a hepaticojejunostomy performed 10 years previously.

RESULTS

Ascaris lumbricoides was found in the right intrahepatic bile duct, that had not been identified by multiple radiologic modalities. The worm was sent to the pathology department for identification. A Fogarty catheter was passed into the hepatic ducts for successful stone extraction. The hepaticojejunostomy was revised, with catheter placement in the Roux limb to accommodate radiologic stone extraction as necessary. Post-operatively, she was given a single dose of albendazole and discharged on hospital day 19.

CONCLUSION

The worm was likely the nidus for the stricture and stone formation. Surgical exploration of the biliary tree was required to diagnose and treat her condition accurately. This case is unique in that typical means of diagnosis failed to identify the causative agent of hepatolithiasis because of the prior Roux-en-Y hepaticojejunostomy.

Classification, diagnosis, and management of cholangiocarcinoma

Cholangiocarcinomas (CCAs) are tumors that develop along the biliary tract. Depending on their site of origin, they have different features and require specific treatments. Classification of CCAs into intrahepatic, perihilar, and distal subgroups has helped standardize the registration, treatment, and study of this lethal malignancy. Physicians should remain aware that cirrhosis and viral hepatitis B and C are predisposing conditions for intrahepatic CCA. Treatment options under development include locoregional therapies and a chemotherapy regimen of gemcitabine and cisplatin. It is a challenge to diagnose perihilar CCA, but an advanced cytologic technique of fluorescence in situ hybridization for polysomy can aid in diagnosis. It is important to increase our understanding of the use of biliary stents and liver transplantation in the management of perihilar CCA, as well as to distinguish distal CCAs from pancreatic cancer, because of different outcomes from surgery. We review advances in the classification, diagnosis, and staging of CCA, along with treatment options.

[An Asian man with recurrent abdominal pain]

Recurrent pyogenic cholangitis (RPC), or oriental cholangiohepatitis, is characterized by intrabiliary pigment stone formation, whose main manifestation consists of recurrent episodes of cholangitis, although other biliopancreatic complications can also occur. RPC develops mainly in Asian patients, in whom this entity is one of the main causes of acute abdominal pain. The differential diagnosis should be established with all other entities associated with intrahepatic stone formation, which is more common in Asian countries compared with the predominance of gallstone formation in the West. The diagnostic and therapeutic approach requires collaboration among gastroenterologists, radiologists and gastrointestinal surgeons. We review the most important clinical, diagnostic and therapeutic features of this entity, which, although clearly predominant in Asia, is increasingly diagnosed in our setting.

Risk factors for cholangiocarcinoma

Cholangiocarcinoma (CC) is the second most common primary hepatic malignancy after hepatocellular cancer. CC accounts for approximately 10%-25% of all hepatobiliary malignancies. There are considerable geographic and demographic variations in the incidence of CC. There are several established risk factors for CC, including parasitic infections, primary sclerosing cholangitis, biliary-duct cysts, hepatolithiasis, and toxins. Other less-established potential risk factors include inflammatory bowel disease, hepatitis C virus, hepatitis B virus, cirrhosis, diabetes, obesity, alcohol drinking, tobacco smoking, and host genetic polymorphisms. In studies where the distinction between intra- and extrahepatic CC was used, some potential risk factors seem to have a differential effect on CC, depending on the site. Therefore, the consistent use of a more refined classification would allow a better understanding of risk factors for CC.

Prevalence of clonorchiasis in patients with gastrointestinal disease: A Korean nationwide multicenter survey

AIM: To investigate prevalence of Clonorchis sinensis in patients with gastrointestinal symptoms, and the relation of the infection to hepatobiliary diseases in 26 hospitals in Korea.

METHODS: Consecutive patients who had been admitted to the Division of Gastroenterology with gastrointestinal symptoms were enrolled from March to April 2005. Of those who had been diagnosed with clonorchiasis, epidemiology and correlation between infection and hepatobiliary diseases were surveyed by questionnaire.

RESULTS: Of 3080 patients with gastrointestinal diseases, 396 (12.9%) had clonorchiasis and 1140 patients (37.2%) had a history of eating raw freshwater fish. Of those with a history of raw freshwater fish ingestion, 238 (20.9%) patients had clonorchiasis. Cholangiocarcinoma was more prevalent in C. sinensis-infected patients than non-infected patients [34/396 (8.6%) vs 145/2684 (5.4%), P = 0.015]. Cholangiocarcinoma and clonorchiasis showed statistically significant positive cross-relation (P = 0.008). Choledocholithiasis, cholecystolithiasis, cholangitis, hepatocellular carcinoma, and biliary pancreatitis did not correlate with clonorchiasis.

CONCLUSION: Infection rate of clonorchiasis was still high in patients with gastrointestinal diseases in Korea, and has not decreased very much during the last two decades. Cholangiocarcinoma was related to clonorchiasis, which suggested an etiological role for the parasite.

Gallstones and Clonorchis sinensis infection: a hospital-based case-control study in Korea

BACKGROUND AND AIM

A high prevalence of intrahepatic stones in some areas of East Asia has been believed to be related with Clonorchis sinensis infection. The authors conducted a hospital-based case-control study to evaluate the role of Clonorchis sinensis infection as a risk factor for the development of gallstones in Korea.

METHODS

The cases of 138 patients with gallstones (intrahepatic 44, gallbladder 67, and extrahepatic 27) and matched controls underwent microscopy for C. sinensis, serological tests for C. sinensis using enzyme-linked immunosorbent assay, radiological examinations, and interviews concerning the history of eating raw freshwater fish. We assessed a relationship of three types of gallstones and variables regarding C. sinensis by using univariate and multivariate statistical analyses.

RESULTS

Univariate statistical analyses showed that radiological evidence of C. sinensis and recent history of eating raw freshwater fish were related to an increased risk of intrahepatic stones (P = 0.0002 and 0.0039, respectively). According to multivariate statistical analyses, radiological evidence of C. sinensis was the only risk factor for intrahepatic stones (odds ratio = 7.835; 95% confidence interval = 1.671-36.724). Any evidence regarding C. sinensis was not related to an increased risk of either gallbladder or extrahepatic stones.

CONCLUSION

Radiological evidence of C. sinensis was significantly associated with intrahepatic stones.

Gallstone disease. Pathogenesis of gallstones: A genetic perspective

Cholelithiasis is one of the most prevalent gastroenterological diseases, imposing a huge economic burden on health-care systems. Gallbladder stones form when the concentration of cholesterol or bilirubin exceeds the solubility in the bile salt and phospholipid-rich bile. The physiology of biliary lipid secretion by a number of specialized transport proteins has recently been elucidated, and underlying genetic defects in these proteins have been identified as susceptibility factors for gallstone disease. Recent studies of identical twins and family strongly support the idea of a genetic component to gallstone disease. Epidemiological studies in high-risk populations indicate that gallstone formation is caused by multiple environmental influences and common genetic factors and their interactions. Monogenic subtypes of cholelithiasis, such as biliary lipid transporter deficiencies, appear to be rare. The characterization of lithogenic genes in knockout and transgenic mice, and the identification of many gallstone susceptibility loci in inbred mice, provide the basis for studies of the corresponding genes in patients with gallstones. The transfer of findings from mouse genetics to the bedside might lead to new strategies for individual risk assessment and reveal molecular targets for the development of new treatment strategies.