Congenital dilatation of the intrahepatic bile ducts (Caroli's disease)

Caroli's disease: Liver resection and liver transplantation. Experience in 33 patients

BACKGROUND

The aim of this study was to review and discuss our observations on 33 patients who underwent surgical treatment for Caroli's disease (CD), focusing on diagnosis, current surgical management, and long-term outcome.

METHODS

Between May 1993 and June 2004, 642 liver resections and 286 liver transplantations in 252 patients were performed in our department of surgery. Thirty-three patients were referred to our center for diagnostic and therapeutic management of CD. Prior surgical interventions for hepatobiliary disorders, current diagnostic and surgical procedures, procedure-specific complications, duration of hospital stay, duration of follow-up, outpatient information, and long-term outcome were reviewed.

RESULTS

Fifteen male and 18 female patients were treated in this study. Initial symptoms and signs of the disease noted in our patients included right upper quadrant pain, fever, and jaundice. In 2 of the 33 patients, we noted clinical evidence of cirrhosis followed by histologic confirmation. One patient suffered from variceal bleeding. In 26 patients, diagnoses were established by a combined endoscopic retrograde cholangiopancreatography, ultrasonography, and computed tomographic studies. The disease was localized in 25 and diffuse in 8 patients. Liver resection was carried out in 29 patients. Partial hepatectomies were performed in 27 of these 29 at our institution. Two female patients with the diffuse disease underwent orthotopic liver transplantation. Thirteen of the 31 patients who underwent surgery at our institution had an uneventful postoperative course. Fourteen patients had minor postoperative complications and responded well to medical management. Four patients had major complications that required further surgical treatment. Two patients died of complications related to postoperative hemorrhage and sepsis. Two patients with intrahepatic cholangiocarcinoma died because of primary tumor progress. One patient with cholangiocarcinoma died 1 year after a successful left hepatectomy because of metastatic disease recurrence. The long-term results of the 26 surviving patients were assessed during a mean follow-up of 3.7 years (range, 1-11 years). All 26 patients remained free of biliary symptoms or complications. In 25 patients, surgery including liver transplantation was curative.

CONCLUSIONS

Partial hepatectomy for localized CD is potentially curative. In patients with diffuse CD, liver transplantation provides gratifying long-term results.

Caroli's disease: radiologic spectrum with pathologic correlation

OBJECTIVE

The purpose of our study was to describe the spectrum of radiologic and pathologic features of Caroli's disease.

CONCLUSION

Caroli's disease and its complications have overlapping radiologic appearances that reflect the underlying pathology of fibrosis, ductal dilatation, cholangitis, stone formation, and malignancy.

US approach to jaundice in infants and children

High-resolution real-time ultrasonography (US) serves as an important tool for differentiation of obstructive and nonobstructive causes of jaundice in infants and children, independent of liver function. Unconjugated hyperbilirubinemia occurs in approximately 60% of normal term infants and in 80% of preterm infants. Persistence of neonatal jaundice beyond 2 weeks of age demands US evaluation to differentiate between the three most common causes: hepatitis, biliary atresia, and choledochal cyst. In all three conditions, the hepatic echotexture is diffusely coarse and hyperechoic, but this appearance may be seen in a variety of hepatic inflammatory, obstructive, and metabolic processes. Thus, hepatic scintigraphy and at times percutaneous liver biopsy are necessary to narrow the differential diagnosis and to identify patients who require more invasive techniques (eg, intraoperative cholangiography). US is useful for demonstrating inspissated bile and biliary duct stones. In infants, stones are usually secondary to obstructive congenital anomalies of the biliary tract, total parenteral nutrition, furosemide treatment, phototherapy, dehydration, infection, hemolytic anemia, and short-gut syndrome, whereas in older children, stones are usually associated with sickle cell disease, bowel resection, hemolytic anemia, and choledochal cyst. Jaundice in infants and children may also be due to cirrhosis, benign strictures, and neoplastic processes.

Radionuclide scintigraphy in Caroli's disease

Congenital cystic dilatation of the intrahepatic bile ducts involving the major intrahepatic radicles was first described by Caroli and hence named as Caroli's disease. We present here a case in which the only symptom was intermittent pain in the abdomen for last one-and-a-half-year and a radionuclide scan done effectively, not only diagnosed the disease but also the associated cholangitis.

Hepatic arterial color Doppler signals in Caroli's disease

Three siblings with congenital dilatation of the intrahepatic bile ducts (Caroli's disease) are presented. Bile duct pathology was associated with congenital hepatic fibrosis and polycystic renal disease in all three patients. On color Doppler imaging (CD imaging), multiple small color Doppler signals were observed in the vascular radicles within the dilated bile ducts or in the center of the lumen apart from the vascular radicles, as well as in other well-known sonographic findings such as bile duct dilatations and bilary calculi. Doppler frequency spectral analysis confirmed all these color signals as arterial in origin in all patients, revealing pulsatile wave patterns. In spite of the fact that portal venous radicles have been well described on conventional sonograms or computed tomography (CT), continuous wave patterns of venous flow on spectral analysis were not detected in all patients. Identification of such less emphasized arterial flow may add another clue in the diagnosis and pathogenesis of this rare disease entity. In conclusion, color Doppler signals of arterial wave pattern within the dilated bile ducts are another helpful diagnostic criteria in previously reported sonographic findings, and these color signals are easily depicted on sonograms with color mapping.

Caroli's disease. Case report with unusual features and a review of current diagnostic and treatment modalities

This is a case report of the simple form of Caroli's disease in a 36 year old Irish woman who has extensive bilobar involvement without congenital hepatic fibrosis or portal hypertension. The difficulty of diagnosis and the intractable nature of the disease are emphasised and recent improvements in diagnosis and management are discussed.

Congenital hepatic fibrosis with saccular dilatation of intrahepatic bile ducts and infantile polycystic kidneys

A case report is presented of a child who died in the neonatal period and who had the sonographic findings of multiple, tubular, fluid-filled spaces in the liver characteristic of Caroli's disease. There was an echodense renal cortex and pyramids. Necropsy findings were consistent with Caroli's disease but the liver also showed evidence of congenital hepatic fibrosis and there was infantile type polycystic disease of the kidneys.

Caroli's Disease: a premalignant condition?

This study reports four new cases of Caroli's disease complicated by the development of cholangiocarcinoma. Caroli's disease appears to be a premalignant condition, but early diagnosis of malignancy in the cyst wall is difficult because signs of ductal stenosis develop slowly and treatment is often based on erroneous diagnosis of recurrent cholangitis. When carcinoma is present, operative intervention makes no difference in survival. In patients with Caroli's disease, adequate intraductal and hepatic biopsies should be obtained at the first operation. These patients should be followed carefully, and malignant growth should be suspected when cholangitis occurs despite patent anastomoses. Earlier diagnosis will obviate repeated operations in patients with malignant Caroli's disease.

Preoperative scintigraphic evaluation of the liver and biliary tract in Caroli's disease

Caroli's disease (congenital dilatation of the intrahepatic bile ducts) is a rare condition which is usually diagnosed postoperatively. Scintigraphic evaluation of this entity is very limited. We report here a patient with Caroli's disease in whom a dichotomy in hepatic uptake of 99mTc-HIDA (hot spots) and 99mTc-colloid (cold spots) was observed, leading to a correct preoperative evaluation of the disease.

Role of hepatobiliary scintigraphy in diagnosis of Caroli's disease

Caroli's disease is a relatively uncommon form of hepatic cystic disease which, in the past, was best diagnosed conclusively by surgical exploration. The present case is reported to illustrate the utility of technetium-labeled hepatobiliary agents in establishing the diagnosis.