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Memis B, Saka B, Roa JC, Bandyopadhyay S, Reid M, Bagci P, Aktas BK, Armutlu A, Basturk O, Adsay NV. Eosinophilic Cholecystitis and Eosinophils in Gallbladder Injuries: A Clinicopathological Analysis of 1050 Cholecystectomies. Diagnostics (Basel) 2023; 13:2559. [PMID: 37568922 PMCID: PMC10417514 DOI: 10.3390/diagnostics13152559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/20/2023] [Accepted: 07/23/2023] [Indexed: 08/13/2023] Open
Abstract
"Eosinophilic cholecystitis" has been an elusive concept. Around 1050 consecutive cholecystectomies with chronic (CC, n = 895), subacute (SAC, n = 100), and acute cholecystitis (AC, n = 55) were reviewed for eosinophilic infiltration. Eosinophilic hot spots (>40 eosinophils/HPF) were seen in 63% of SAC and 35% of AC (vs. 6% of CC, p < 0.001). Eosinophils were mostly encountered in areas of wall thickening, revealing edema with early collagenization and young tissue-culture-type fibroblasts. However, in ten chronic cholecystitis patients (<1%), prominent eosinophilia with eosinophil-rich foci (>100 eosinophils/HPF) was noted. These ten cases, classified as "eosinophilic cholecystitis", were analyzed further: The patients were relatively young (mean age = 43 years), with a 9:1 female:male ratio. None had blood eosinophilia/eosinophilia syndromes. Although one had ulcerative colitis, others did not have any autoimmune diseases. The mean gallbladder wall thickness was 3.5 mm (vs. 4.2 mm in ordinary CC). In conclusion, eosinophils are a part of especially subacute injuries in the gallbladder. They are typically condensed in the areas of healing and appear to signify a distinctive state of injury in which there are erosions leading to slow/sustained exposure of the mural tissues to the bile contents that induce chemical injury/recruit eosinophils. Eosinophilic cholecystitis is a very uncommon occurrence and appears to be an exaggerated response in allergic patients who are prone to recruit eosinophils in reaction to injury.
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Affiliation(s)
- Bahar Memis
- Department of Pathology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul 34396, Turkey
| | - Burcu Saka
- Department of Pathology, Koc University, Istanbul 34450, Turkey
| | - Juan Carlos Roa
- Department of Pathology, Pontificia Universidad Catolica de Chile, Center for Cancer Prevention and Control (CECAN), Millennium Institute on Immunology and Immunotherapy (IMII), Santiago 8331150, Chile
| | | | - Michelle Reid
- Department of Pathology, Emory University, Atlanta, GA 30322, USA
| | - Pelin Bagci
- Department of Pathology, Marmara University, Istanbul 34854, Turkey
| | - Berk Kaan Aktas
- Department of Pathology, Koc University, Istanbul 34450, Turkey
| | - Ayse Armutlu
- Department of Pathology, Koc University, Istanbul 34450, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - N. Volkan Adsay
- Department of Pathology, Koc University, Istanbul 34450, Turkey
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2
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Takahashi K, Ohyama H, Takiguchi Y, Sekine Y, Toyama S, Yamada N, Sugihara C, Kan M, Ouchi M, Nagashima H, Iino Y, Kusakabe Y, Okitsu K, Ohno I, Kato N. Secondary Sclerosing Cholangitis After Emphysematous Cholecystitis. ACG Case Rep J 2023; 10:e01016. [PMID: 36968126 PMCID: PMC10036046 DOI: 10.14309/crj.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/21/2023] [Indexed: 03/24/2023] Open
Abstract
A 64-year-old woman was diagnosed with emphysematous cholecystitis. An open cholecystectomy was performed immediately. After the cholecystectomy, jaundice and multiple bile duct strictures that were not present preoperatively appeared. The patient was diagnosed with sclerosing cholangitis secondary to emphysematous cholecystitis. Endoscopic biliary stenting and endoscopic biliary balloon dilatation were performed. However, jaundice did not improve. She developed candidemia 75 days after cholecystectomy. The patient died of multiple organ failures 92 days after cholecystectomy. Although rare, secondary sclerosing cholangitis occurred after emphysematous cholecystitis, and endoscopic treatment was ineffective in this case.
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Affiliation(s)
- Koji Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroshi Ohyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuichi Takiguchi
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yu Sekine
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shodai Toyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Nana Yamada
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Chihei Sugihara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Motoyasu Kan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mayu Ouchi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroki Nagashima
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yotaro Iino
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuko Kusakabe
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kohichiroh Okitsu
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Izumi Ohno
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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3
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Möller K, Braden B, Culver EL, Jenssen C, Zadeh ES, Alhyari A, Görg C, Ignee A, Hocke M, Dong Y, Sun S, Faiss S, Dietrich CF. Secondary sclerosing cholangitis and IgG4-sclerosing cholangitis - A review of cholangiographic and ultrasound imaging. Endosc Ultrasound 2023; 12:181-199. [PMID: 36588352 PMCID: PMC10237613 DOI: 10.4103/eus-d-22-00208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/08/2022] [Indexed: 01/01/2023] Open
Abstract
Sclerosing cholangitis (SC) represents a spectrum of chronic progressive cholestatic diseases of the intrahepatic and/or extrahepatic biliary system characterized by patchy inflammation, fibrosis, and stricturing. Primary and secondary SC must be distinguished given the different treatment modalities, risks of malignancy, and progression to portal hypertension, cirrhosis, and hepatic failure. This review focuses on secondary SC and the pathogenic mechanisms, risk factors, clinical presentation, and novel imaging modalities that help to distinguish between these conditions. We explore the detailed use of cholangiography and ultrasound imaging techniques.
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Affiliation(s)
- Kathleen Möller
- Medical Department I/Gastroenterology, Sana Hospital Lichtenberg, Berlin, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Emma L. Culver
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland GmbH, Strausberg, Wriezen, Germany
- Brandenburg Institute of Clinical Medicine at Medical University Brandenburg, Neuruppin, Germany
| | - Ehsan Safai Zadeh
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Amjad Alhyari
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Christian Görg
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Marburg, Germany
| | - André Ignee
- Department of Internal Medicine – Gastroenterology and Rheumatology; Klinikum Wuerzburg Mitte, Wuerzburg, Germany
| | - Michael Hocke
- Medical Department II, Helios Klinikum Meiningen, Meiningen, Germany
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Siyu Sun
- Department of Endoscopy Center, Shengjing Hospital of China Medical University, Liaoning Province, China
| | - Siegbert Faiss
- Medical Department I/Gastroenterology, Sana Hospital Lichtenberg, Berlin, Germany
| | - Christoph F. Dietrich
- Department of Internal Medicine (DAIM), Hirslanden Private Hospital, Beau Site, Salem und Permanence, Bern, Switzerland
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4
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Motoya M, Takai S, Moriya H, Hirano T, Wagatsuma K, Numata Y, Kawakami Y, Masaki Y, Ishigami K, Murota A, Nakase H. Sustained Eosinophilic Cholangitis Due to a Mite Allergy Mimicking Sclerosing Cholangitis. Intern Med 2022; 61:2477-2482. [PMID: 35110477 PMCID: PMC9449603 DOI: 10.2169/internalmedicine.8323-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Eosinophilic cholangiopathy (EC) presents with thickening and stenosis of the bile duct wall that is histologically characterized by eosinophil infiltration. The diagnosis is often difficult. We herein report a patient who had been followed up with a diagnosis of primary sclerosing cholangitis but had a final diagnosis of EC based on eosinophilia, histological findings of bile duct and liver biopsy specimens, and a review of a previous surgical specimen of the gallbladder. Antigen tests, isolation from her house, and accidental re-exposure to the antigen revealed that the causative antigen was the mite Dermatophagoides pteronyssinus.
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Affiliation(s)
- Masayo Motoya
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Shun Takai
- Department of Gastroenterology, Hakodate Goryoukaku Hospital, Japan
| | - Hiroshi Moriya
- Department of Gastroenterology, Hakodate Goryoukaku Hospital, Japan
| | - Takehiro Hirano
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Kohei Wagatsuma
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Yasunao Numata
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Yujiro Kawakami
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Yoshiharu Masaki
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Keisuke Ishigami
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Ayako Murota
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
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5
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Abstract
A 63-year old female patient with a medical history of hypereosinophilic syndrome with neurological and pulmonary involvement presented for a routine follow-up. The patient was asymptomatic but a routine scheduled ultrasound showed a gallbladder polyp of 19mm. One month later this polyp had grown to 36 mm. On magnetic resonance imaging of the liver there was a suspicion of gallbladder cancer and for this reason cholecystectomy was performed. Pathology however showed eosinophilic infiltration. Serum analysis showed an increase in her eosinophil count. The diagnosis of hypereosinophilic syndrome with eosinophilic infiltration of the gallbladder was made. The dose of corticosteroids was augmented and she recovered completely post-operatively with no residual flares of other organ damage during follow up.
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6
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Li W, Jiang F, Li X, Li H, Zheng Z. A rare case of eosinophilic cholangiopathy. Int J Immunopathol Pharmacol 2021; 34:2058738420941752. [PMID: 32684063 PMCID: PMC7372610 DOI: 10.1177/2058738420941752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Eosinophilic cholangiopathy is termed as a rare, benign, and self-limiting
disease. Moreover, the interference of malignant tumor to diagnosis and the
changing process of disease make the accurate treatment proposal challenging. A
significant number of patients require surgery for the definitive diagnosis and
resolution of symptoms. We put forward a case of eosinophilic cholangiopathy
infiltrating the gallbladder and bile duct with bone marrow involved, coupled
with peripheral eosinophilia. The patient underwent a successful treatment using
laparoscopic cholecystectomy and steroids, instead of extrahepatic bile duct
excision with Roux-en-Y hepaticojejunostomy. The patient gets an accurate
treatment in a minimally invasive manner. In conclusion, surgery refers to not
only a diagnostic methodology but also a treatment. When the bile duct and
gallbladder are involved at the same time, and cannot distinguish benign and
malignant diseases, laparoscopic cholecystectomy is feasible, the effect is the
same, and the symptoms of eosinophilic cholecystitis are relieved.
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Affiliation(s)
- Wenya Li
- Wenzhou Medical University, Wenzhou, China
| | - Feizhao Jiang
- Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaoxiao Li
- Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hong Li
- Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhihai Zheng
- Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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7
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Klindt C, Jensen B, Brandenburger T, Feldt T, Killer A, Schimmöller L, Antoch G, Senff T, Hauka S, Timm J, Bahners BH, Seidl M, Esposito I, Luedde T, Bode JG, Keitel V. Secondary sclerosing cholangitis as a complication of severe COVID-19: A case report and review of the literature. Clin Case Rep 2021; 9:e04068. [PMID: 34084492 PMCID: PMC8142800 DOI: 10.1002/ccr3.4068] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 12/24/2022] Open
Abstract
This case of secondary sclerosing cholangitis (SSC-CIP) emphasizes the need to provide follow-up care for patients that have recovered from COVID-19 in order to understand the complexity of SARS-CoV-2 associated sequela.
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Affiliation(s)
- Caroline Klindt
- Clinic for Gastroenterology, Hepatology and Infectious DiseasesHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Björn‐Erik Jensen
- Clinic for Gastroenterology, Hepatology and Infectious DiseasesHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Timo Brandenburger
- Department of AnaesthesiologyMedical FacultyHeinrich‐Heine UniversitätDüsseldorfGermany
| | - Torsten Feldt
- Clinic for Gastroenterology, Hepatology and Infectious DiseasesHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Alexander Killer
- Clinic for Gastroenterology, Hepatology and Infectious DiseasesHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Lars Schimmöller
- Department of Diagnostic and Interventional RadiologyHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Gerald Antoch
- Department of Diagnostic and Interventional RadiologyHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Tina Senff
- Institute of VirologyHeinrich Heine UniversityUniversity HospitalDüsseldorfGermany
| | - Sandra Hauka
- Institute of VirologyHeinrich Heine UniversityUniversity HospitalDüsseldorfGermany
| | - Jörg Timm
- Institute of VirologyHeinrich Heine UniversityUniversity HospitalDüsseldorfGermany
| | - Bahne Hendrik Bahners
- Clinic for Gastroenterology, Hepatology and Infectious DiseasesHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Maximilian Seidl
- Institute of PathologyHeinrich‐Heine University and University HospitalDüsseldorfGermany
| | - Irene Esposito
- Institute of PathologyHeinrich‐Heine University and University HospitalDüsseldorfGermany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious DiseasesHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Johannes G. Bode
- Clinic for Gastroenterology, Hepatology and Infectious DiseasesHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Verena Keitel
- Clinic for Gastroenterology, Hepatology and Infectious DiseasesHeinrich‐Heine‐University DüsseldorfDüsseldorfGermany
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8
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Hammami MB, Ohanisian L, Kaur N, Irshad A, Sidley A. A Challenging Diagnosis of Eosinophilic Cholangitis Requiring Resection of Extrahepatic Bile Ducts. Cureus 2019; 11:e4925. [PMID: 31423401 PMCID: PMC6692105 DOI: 10.7759/cureus.4925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Eosinophilic cholangitis (EC) is a rare benign disease characterized by transmural eosinophilic infiltration of the biliary tree that may result in biliary stricture and obstructive jaundice. The pathophysiology remains unknown but is theorized to involve an allergic mechanism. EC is diagnostically challenging as it may mimic cholangiocarcinoma (CCA) clinically and radiographically and involves a broad differential diagnosis including benign and malignant pathologies. In addition to tumor markers, ultrasonography, contrast-enhanced computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP), proper evaluation of malignant processes may need biopsy through endoscopic retrograde cholangiopancreatography (ERCP) and surgical exploration. We present the case of a 47-year-old female diagnosed with EC upon exploratory laparotomy.
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Affiliation(s)
- Muhammad B Hammami
- Internal Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Levonti Ohanisian
- Orthopaedic Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Navneet Kaur
- Internal Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Ahmad Irshad
- Internal Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Angel Sidley
- Pediatrics, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
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9
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Bali M, Pezzullo M, Pace E, Morone M. Benign biliary diseases. Eur J Radiol 2017; 93:217-228. [DOI: 10.1016/j.ejrad.2017.05.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 02/07/2023]
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10
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Adult bile duct strictures: differentiating benign biliary stenosis from cholangiocarcinoma. Med Mol Morphol 2016; 49:189-202. [PMID: 27350291 DOI: 10.1007/s00795-016-0143-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/04/2016] [Indexed: 12/17/2022]
Abstract
Biliary epithelial cells preferentially respond to various insults under chronic pathological conditions leading to reactively atypical changes, hyperplasia, or the development of biliary neoplasms (such as biliary intraepithelial neoplasia, intraductal papillary neoplasm of the bile duct, and cholangiocarcinoma). Moreover, benign biliary strictures can be caused by a variety of disorders (such as IgG4-related sclerosing cholangitis, eosinophilic cholangitis, and follicular cholangitis) and often mimic malignancies, despite their benign nature. In addition, primary sclerosing cholangitis is a well-characterized precursor lesion of cholangiocarcinoma and many other chronic inflammatory disorders increase the risk of malignancies. Because of these factors and the changes in biliary epithelial cells, biliary strictures frequently pose a diagnostic challenge. Although the ability to differentiate neoplastic from non-neoplastic biliary strictures has markedly progressed with the advance in radiological modalities, brush cytology and bile duct biopsy examination remains effective. However, no single modality is adequate to diagnose benign biliary strictures because of the low sensitivity. Therefore, understanding the underlying causes by compiling the entire clinical, laboratory, and imaging data; considering the under-recognized causes; and collaborating between experts in various fields including cytopathologists with multiple approaches is necessary to achieve an accurate diagnosis.
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11
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Seo N, Kim SY, Lee SS, Byun JH, Kim JH, Kim HJ, Lee MG. Sclerosing Cholangitis: Clinicopathologic Features, Imaging Spectrum, and Systemic Approach to Differential Diagnosis. Korean J Radiol 2016; 17:25-38. [PMID: 26798213 PMCID: PMC4720808 DOI: 10.3348/kjr.2016.17.1.25] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/23/2015] [Indexed: 12/14/2022] Open
Abstract
Sclerosing cholangitis is a spectrum of chronic progressive cholestatic liver disease characterized by inflammation, fibrosis, and stricture of the bile ducts, which can be classified as primary and secondary sclerosing cholangitis. Primary sclerosing cholangitis is a chronic progressive liver disease of unknown cause. On the other hand, secondary sclerosing cholangitis has identifiable causes that include immunoglobulin G4-related sclerosing disease, recurrent pyogenic cholangitis, ischemic cholangitis, acquired immunodeficiency syndrome-related cholangitis, and eosinophilic cholangitis. In this review, we suggest a systemic approach to the differential diagnosis of sclerosing cholangitis based on the clinical and laboratory findings, as well as the typical imaging features on computed tomography and magnetic resonance (MR) imaging with MR cholangiography. Familiarity with various etiologies of sclerosing cholangitis and awareness of their typical clinical and imaging findings are essential for an accurate diagnosis and appropriate management.
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Affiliation(s)
- Nieun Seo
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jin Hee Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Hyoung Jung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Moon-Gyu Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
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12
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Fragulidis GP, Vezakis AI, Kontis EA, Pantiora EV, Stefanidis GG, Politi AN, Koutoulidis VK, Mela MK, Polydorou AA. Eosinophilic Cholangitis--A Challenging Diagnosis of Benign Biliary Stricture: A Case Report. Medicine (Baltimore) 2016; 95:e2394. [PMID: 26735539 PMCID: PMC4706259 DOI: 10.1097/md.0000000000002394] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
When confronting a biliary stricture, both benign and malignant etiologies must be carefully considered as a variety of benign biliary strictures can masquerade as hilar cholangiocarcinoma (CCA). Therefore, patients could undergo a major surgery despite the possibility of a benign biliary disease. Approximately 15% to 24% of patients undergoing surgical resection for suspected biliary malignancy will have benign pathology. Eosinophilic cholangitis (EC) is a rare benign disorder of the biliary tract, which can cause obstructive jaundice and can pose a difficult diagnostic task. We present a rare case of a young woman who was referred to our hospital with obstructive painless jaundice due to a biliary stricture at the confluence of the hepatic bile ducts, with a provisional diagnosis of cholangiocarcinoma. Though, during her work up she was found to have EC, an extremely rare benign cause of biliary stricture, which is characterized by a dense eosinophilic infiltration of the biliary tree causing stricturing, fibrosis, and obstruction and which is reversible with short-term high-dose steroids. Despite its rarity, EC should be taken into consideration when imaging modalities demonstrate a biliary stricture, especially if preoperative diagnosis of malignancy cannot be made, in the setting of peripheral eosinophilia and the absence of cardinal symptoms of malignancy.
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Affiliation(s)
- Georgios Panagiotis Fragulidis
- From the 2nd Department of Surgery, Aretaieio Hospital, University of Athens, Medical School (GPF, AIV, EAK, EVP, AAP); Department of Gastroenterology, Division of Endoscopy, Athens Naval Hospital (GGS); Department of Pathology, Aretaieio Hospital, University of Athens, Medical School (ANP); 1st Department of Radiology, Aretaieio Hospital, University of Athens, Medical School (VKK); and Department of Hepatology, Evangelismos General Hospital, Athens, Greece (MKM)
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13
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Hokuto D, Yamato I, Nomi T, Yasuda S, Obara S, Yamada T, Chihiro K, Nakajima Y. Eosinophilic cholangitis coexisted with idiopathic thrombocytopenic purpura: Report of a case. Hepatol Res 2015; 45:595-600. [PMID: 24976135 DOI: 10.1111/hepr.12380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 06/19/2014] [Accepted: 06/23/2014] [Indexed: 12/26/2022]
Abstract
Eosinophilic cholangitis is a rare disease of which only 31 cases have been reported. Eosinophilic infiltration causes stricture of the bile duct diffusely or locally, and the imaging of eosinophilic cholangitis resembles primary sclerosing cholangitis or cancer of the bile tract. For eosinophilic cholangitis, treatment with steroid is effective and the prognosis is good. Therefore, its accurate diagnosis is very important. Here, we describe a patient with eosinophilic cholangitis who was also diagnosed with idiopathic thrombocytopenic purpura (ITP). He was treated for ITP using prednisolone, the unexpected sudden interruption of which caused severe deterioration of eosinophilic cholangitis and acute cholecystitis. Cholecystectomy and choledochojejunostomy were performed, and the addition of treatment by prednisolone resulted in a good clinical course. This is the first report on eosinophilic cholangitis coexisting with ITP.
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Affiliation(s)
- Daisuke Hokuto
- Department of Surgery, Nara Medical University, Nara, Japan
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14
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Gunji N, Katakura K, Takahashi A, Fujiwara T, Suzuki R, Watanabe H, Ohira H. Concurrent primary sclerosing cholangitis and eosinophilic colitis. Intern Med 2014; 53:2319-24. [PMID: 25318795 DOI: 10.2169/internalmedicine.53.2765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 39-year-old man presented with diarrhea and abdominal pain. At 26 years of age, he was found to have eosinophilia and abnormal liver function parameters, for which prednisolone therapy was started. He subsequently underwent a liver biopsy and endoscopic retrograde cholangiopancreatography, and received a diagnosis of primary sclerosing cholangitis (PSC). On presentation to our hospital, he was further diagnosed with eosinophilic colitis based on aggravation of diarrhea and severe eosinophilic infiltration in the colonic mucosa. We herein report a rare case of concurrent PSC and eosinophilic colitis.
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Affiliation(s)
- Naohiko Gunji
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, Japan
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Abstract
Sclerosing cholangitis is a chronic cholestatic liver disease defined by both inflammatory and fibrotic changes of the biliary tract leading to diffuse stricture formation. This entity exists in both a primary and secondary form. Here we present a rare case of secondary sclerosing cholangitis due to direct metastasis from a gallbladder adenocarcinoma. A 55-year-old morbidly obese male presented electively with a 2-week history of low back pain and scleral icterus for 2 days. He also described severe epigastric pain that worsened postprandially and a 13 kg weight loss over the previous month. The patient denied any personal or familial history of malignancy or prior liver disease. Laboratory evaluation revealed mild elevation of transaminases with moderately elevated alkaline phosphatase and total bilirubin. Imaging included ultrasound and contrast-enhanced computed tomography of the abdomen and pelvis showing multiple large gallstones and a large tissue density mass within the fundus of the gallbladder. Subsequent endoscopic ultrasound was performed revealing celiac and portal lymphadenopathy with fine needle aspirations demonstrating adenocarcinoma. Over the next 15 days, bilirubin progressively increased. Magnetic resonance cholangiopancreatography was unremarkable. Liver biopsy, performed to exclude other etiologies of liver failure, demonstrated biliary cholestasis. Endoscopic retrograde cholangiopancreatography was then performed and an occlusion cholangiogram revealed diffuse multifocal stricturing of the intrahepatic bile ducts and moderate stenosis of the common bile duct without proximal ductal dilatation. Thus secondary sclerosing cholangitis due to gallbladder adenocarcinoma was diagnosed.
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Azizi L, Raynal M, Cazejust J, Ruiz A, Menu Y, Arrivé L. MR Imaging of sclerosing cholangitis. Clin Res Hepatol Gastroenterol 2012; 36:130-8. [PMID: 22306050 DOI: 10.1016/j.clinre.2011.11.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 11/21/2011] [Accepted: 11/25/2011] [Indexed: 02/04/2023]
Abstract
MRCP is a non-invasive cholangiographic technique used in detection and characterization of bile ducts abnormalities. MRCP features of primary sclerosing cholangitis are randomly distributed annular strictures alternating with slightly dilated bile ducts. Secondary sclerosing processes including ascending, ischemic, caustic, AIDS-related, eosinophilic and autoimmune cholangitis can mimic PSC at MRCP.
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Affiliation(s)
- L Azizi
- Department of radiology, Saint-Antoine hospital, AP-HP, faculté de médecine Pierre-et-Marie-Curie, université Paris-6, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
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Marked infiltration of eosinophils in necrotizing granulomas in the resected hepatic bed after cholecystectomy resulting from gallbladder cancer and metastatic liver cancer is associated with peculiar peripheral eosinophilia. Med Mol Morphol 2012; 45:53-7. [PMID: 22431184 DOI: 10.1007/s00795-011-0555-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 06/24/2011] [Indexed: 10/28/2022]
Abstract
It is known that after transurethral resection of the prostate (TUR-P) or a bladder tumor (TUR-BT), necrotizing granuloma formation associated with massive eosinophil accumulation can be detected at the site of the scar, revealing marked eosinophilia. This condition is called post-TUR prostatitis or cystitis. In the present study, we noticed a similar phenomenon in five patients who underwent cholecystectomy, of whom four had gallbladder adenocarcinoma and one had metastatic liver cancer originating from the rectum. We detected necrotizing granulomas with massive eosinophil accumulation, associated with marked eosinophilia. To induce these phenomena, the interval between the first operation (i.e., cholecystectomy) and the second operation (i.e., resection of the hepatic bed and extrahepatic bile duct) is very important. If the interval was 1 week, no granuloma formation was detected. On the other hand, if it was more than 2 weeks, the resected hepatic bed contained necrotizing granulomas with substantial eosinophil accumulation combined with an increase in peripheral eosinophilia (up to 34% in one case). Secondary resection was necessary to induce eosinophilia after cholecystectomy. In this sense, malignancies possessed a relationship with delayed eosinophilia. In the granulomas, some foreign body-type multinucleated giant cells were positive for both anti-interleukin (IL)-5 and CD68 antibodies. In sharp contrast, no eosinophilia was detected after cholecystectomy, with or without hepatic resection consequent to severe adhesion. Clinicians as well as pathologists should keep in mind that these peculiar phenomena of eosinophil accumulation surrounding the necrotizing granulomas and peripheral eosinophilia after cholecystectomy could occur.
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Hepatobiliary disease associated with hypereosinophilia: a report of two patients and a review of the literature. Dig Dis Sci 2011; 56:3689-94. [PMID: 21647653 DOI: 10.1007/s10620-011-1764-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 05/18/2011] [Indexed: 12/09/2022]
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Eosinophilic cholangitis and cholangiopathy: a sheep in wolves clothing. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2010; 2010:906496. [PMID: 21076681 PMCID: PMC2976516 DOI: 10.1155/2010/906496] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 10/07/2010] [Indexed: 12/13/2022]
Abstract
Background. Eosinophilic cholangitis (EC) is a rare benign disorder of the biliary tract which can cause biliary obstruction. Similar to other disease processes involving the bile ducts, this disorder can pose a difficult diagnostic challenge as it can mimic cholangiocarcinoma.
Methods. A systematic search of the scientific literature was carried out using PubMed to access all publications related to EC. Search keywords that were utilized included “eosinophilic cholangitis,” “etiology,” “treatment,” and “obstructive jaundice.” Results. Twenty-three cases of EC have been reported. Nineteen patients (82.6%) who presented with EC remain disease-free; 15 of these 19 patients (78.9%) with followup time remain disease-free at a mean of 9.7 months (range, 2–24 months).
Conclusion. EC is a rare form of biliary obstruction which can masquerade as a malignancy. Unlike cholangiocarcinoma, EC occurs more commonly in younger patients and in men. Most patients will require surgical treatment.
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Horiuchi K, Kakizaki S, Kosone T, Ichikawa T, Sato K, Takagi H, Mori M, Sakurai S, Fukusato T. Marked eosinophilia as the first manifestation of sclerosing cholangitis. Intern Med 2009; 48:1377-82. [PMID: 19687582 DOI: 10.2169/internalmedicine.48.2223] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We encountered a 45-year-old man who presented with marked eosinophilia as the first manifestation of sclerosing cholangitis. He was found to have a liver dysfunction during a regular physical check up and thereafter consulted our hospital. The laboratory data on admission indicated an elevation of AST (96 IU/L), ALT (136 IU/L) and ALP (1,025 IU/L). Furthermore, the leukocyte count was 18,190/mm(3) and he also showed marked eosinophilia (54.5%, 9,914/mm(3)). There were no atypical findings in the eosinophils. Other diseases causing eosinophilia, including parasite infection, allergic disorders, hypereosinophilic syndromes, drug-induced eosinophilia, malignancies, etc. were all investigated and ruled out. A liver biopsy revealed marked eosinophilic infiltration in the portal area and interlobular bile duct injury. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a slight dilatation of the left intrahepatic bile ducts, but no clear diagnosis could be made at that time. A follow-up liver biopsy and endoscopic retrograde cholangiopancreatography (ERCP) finally revealed a diagnosis of secondary sclerosing cholangitis due to eosinophilic cholangiopathy. According to previous Japanese reports, eosinophilia of more than 5% was reported in 39 of 142 (27.0%) primary sclerosing cholangitis (PSC) patients. Eosinophilic cholangiopathy could cause a condition mimicking PSC and it might be confused as PSC with eosinophilia. The literature contains only about 40 case reports on eosinophilic cholangiopathy, and therefore, to date little attention has been paid to this condition. We should therefore pay attention to this condition when making a differential diagnosis of either PSC or IgG4-related sclerosing cholangitis.
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