Primary sclerosing cholangitis: Updates in diagnosis and therapy

Laparoscopic total colectomy for ulcerative colitis after liver transplantation is feasible

Ulcero-haemorrhagic rectocolitis can occur after liver transplantation for sclerosing cholangitis. Total colectomy with or without proctectomy may be indicated in case of chronic drug-resistant colitis, dysplasia or cancer. Today, laparoscopic approach is the standard for such procedure in non-operated patients. We performed a completely laparoscopic total colectomy 5 years after a liver transplantation. There were a few peritoneal adherences, and we could safely perform the procedure almost as usual. It provided all the advantages of the laparoscopic approach in the post-operative course.

Risk of hepatobiliary cancer after solid organ transplant in the United States

BACKGROUND & AIMS

Studies of liver cancer risk in recipients of solid organ transplants generally have been small, yielding mixed results, and little is known about biliary tract cancers among transplant recipients.

METHODS

We identified incident hepatobiliary cancers among 201,549 US recipients of solid organs, from 1987 through 2008, by linking data from the US transplant registry with 15 cancer registries. We calculated standardized incidence ratios (SIRs), comparing risk relative to the general population. We also calculated incidence rate ratios (RRs), comparing risk for hepatocellular carcinoma (HCC) and total (intrahepatic and extrahepatic) cholangiocarcinoma among subgroups of recipients.

RESULTS

Of transplant recipients, 165 developed hepatobiliary cancers (SIR, 1.2; 95% confidence interval [CI], 1.0-1.4). HCC risk was increased among liver recipients (SIR, 1.5; 95% CI, 1.0-2.2), especially 5 or more years after transplant (SIR, 1.8; 95% CI, 1.0-3.0). Cholangiocarcinoma was increased among liver (SIR, 2.9; 95% CI, 1.6-4.8) and kidney recipients (SIR, 2.1; 95% CI, 1.3-3.1). HCC was associated with hepatitis B virus (RR, 3.2; 95% CI, 1.3-6.9), hepatitis C virus (RR, 10; 95% CI, 5.9-16.9), and non-insulin-dependent diabetes (RR, 2.5; 95% CI, 1.2-4.8). Cholangiocarcinoma was associated with azathioprine maintenance therapy (RR, 2.0; 95% CI, 1.1-3.7). Among liver recipients, primary sclerosing cholangitis was associated with an increased risk of cholangiocarcinoma, compared with the general population (SIR, 21; 95% CI, 8.2-42) and compared with liver recipients without primary sclerosing cholangitis (RR, 12.3; 95% CI, 4.1-36.4).

CONCLUSIONS

Risks for liver and biliary tract cancer are increased among organ transplant recipients. Risk factors for these cancers include medical conditions and potentially medications taken by recipients.

Effects of intraperitoneal melatonin on caustic sclerosing cholangitis due to scolicidal solution in a rat model

BACKGROUND

Hydatid disease is a worldwide health problem. Treatment is surgical or percutaneous, using scolicidal agents. Caustic sclerosing cholangitis might develop after the contact of scolicidal agents with the biliary ducts. Melatonin, an antioxidant, anti-inflammatory, and anticarcinogenic agent, might be used in the treatment of caustic sclerosing cholangitis due to its possible preventive effects on fibrosis and cell damage.

OBJECTIVE

The aim of the study was to investigate the effects of melatonin on an experimentally developed caustic sclerosing cholangitis with scolicidal solution (formalin) in a rat model.

METHODS

Forty female Sprague-Dawley rats aged 11 to 13 weeks and weighing 250 ± 30 g were randomly assigned to 1 of 4 groups of 10: formalin 5% at 0.5 mL/d + melatonin placebo; formalin placebo + intraperitoneal melatonin 10 mg/kg/d; formalin 5% at 0.5 mL/d + melatonin 10 mg/kg/d; and formalin placebo and melatonin placebo (control). Hepatobiliary function was assessed using dynamic scintigraphy with technetium-99m-mebrofenin on study day 60. The histology of the liver and biliary duct specimens was examined on study day 60. In each group, histopathologic alterations were scored as absent, slight, mild, or severe.

RESULTS

Mean severity scores for parenchymal necrosis in the liver (P < 0.01), portal fibrosis (P < 0.01), biliary duct proliferation (P < 0.001), cholangitis/ pericholangitis (P < 0.01), hyperemia in the biliary ducts (P < 0.01), and fibrosis (P < 0.01) were significantly lower in rats treated with formalin + melatonin compared with those treated with formalin alone. No significant differences were observed between the 3 treatment groups with respect to t½, a parameter used to assess the secretion function of the hepatocytes. However, the t½ was significantly longer in the treatment groups compared with controls (P < 0.001).

CONCLUSION

In this experimental study in a rat model of caustic sclerosing cholangitis, the histopathologic and scintigraphic findings suggested that melatonin is effective in attenuating the damage caused by scolicidal agents on the liver and biliary ducts.

Magnetic resonance imaging of the pediatric pancreaticobiliary system

Magnetic resonance cholangiopancreatography (MRCP) is an extremely useful tool for evaluating a wide variety of disorders affecting the pancreaticobiliary system in neonates/infants, children, and adolescents. This imaging technique has numerous distinct advantages over alternative diagnostic modalities, such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography, including its noninvasive nature and lack of ionizing radiation. Such advantages make MRCP the preferred first-line method for advanced imaging the pediatric pancreaticobiliary tree, after ultrasonography. This article presents a contemporary review of the use of MRCP in the pediatric population, including techniques, indications, and the imaging appearances of common and uncommon pediatric disorders.

Coexistence of primary sclerosing cholangitis in a patient with myasthenia gravis

Myasthenia gravis (MG) is an immune-mediated disease that compromises the postsynaptic membrane of the neuromuscular junction. Primary sclerosing cholangitis (PSC) is considered an immune-mediated cholestatic liver disease. Both MG and PSC include an autoimmune pathogenesis, so there is some evidence that patients with MG or PSC have a higher risk of developing autoantibodies and other immune disorders than normal controls, but the coexistence of these two disorders has never been documented. We report a 40-year-old woman who presented with MG when she was 20 years old and developed PSC 20 years after a thymectomy. Liver biochemistry revealed cholestasis. Magnetic resonance imaging showed multifocal strictures and beads involving the intrahepatic bile ducts. A liver biopsy confirmed sclerosing cholangitis. Serological analysis demonstrated positive autoantibodies (Anti-nuclear antibodies, anti-smooth muscle antibodies). Repetitive stimulation had a decremental response, and antibodies to acetylcholine receptors were detectable. To our knowledge, this is the first case of PSC in a patient with MG. The main characteristics of both MG and PSC combination are discussed.

Primary sclerosing cholangitis as an intractable disease

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown origin which eventually results in liver cirrhosis. The disease is reported to be more common among the Western population than in the Asian population. Asian experience remains limited. Diagnosis and treatment standards in the Far East have largely followed those in the West, including liver transplantation. Unlike in the West, however, recent reports from Japan have presented with a higher recurrence rate of PSC after liver transplantation, suggesting the intractable nature of the disease even after the replacement of the entire affected organ.

Extensively spreading intraepithelial bile duct carcinoma causing multiple bile duct strictures: report of three cases

Extensive intraepithelial spread of bile duct carcinoma is a common feature, seen in approximately 18% of all cases. However, this spread is rarely accompanied by bile duct strictures. We herein describe three cases of bile duct carcinoma with multiple bile duct strictures due to extensive intraepithelial spread. In all three cases, the spread of intraepithelial cancer extended into the epithelium of the peribiliary glands along the intrahepatic bile ducts with marked fibrosis on histopathological examination. It is speculated that peribiliary gland involvement by superficially spreading bile duct cancer and subsequent obstructive glandular inflammation with fibrosis might cause intrahepatic bile duct strictures even without interstitial cancer invasion.

The natural history of inflammatory bowel disease and primary sclerosing cholangitis after liver transplantation--a single-centre experience

OBJECTIVE

To describe the natural history of primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) after liver transplant, the predictors of PSC and IBD recurrence, and the interaction of these disease processes.

METHODS

Data regarding patients who received liver transplants for PSC at the University of Alberta Hospital (Edmonton, Alberta) from 1989 to 2006 were retrospectively reviewed. Recurrent PSC (rPSC) was defined by the Mayo Clinic criteria. Cox proportional hazards modelling and Kaplan-Meier statistics were used.

RESULTS

Fifty-nine patients were studied, with a median follow-up of 68 months. A total of 71.2% of patients were diagnosed with IBD pretransplant. Clinical IBD severity post-transplant compared with severity pretransplant was unchanged in 67%, worse in 26.5% and improved in 6.1% of patients. Twenty-five per cent of patients developed rPSC posttransplant. The occurrence of at least one episode of acute cellular rejection (hazard ratio 5.7; 95% CI 1.3 to 25.8) and cytomegalovirus mismatch (hazard ratio 4.2; 95% CI 1.1 to 15.4) were found to be significant predictors of rPSC. Although not statistically significant, there was no rPSC in patients without pre- or post-transplant IBD, and in only one patient with a colectomy. Actuarial patient survival rates at one, five and 10 years posttransplant were 97%, 86% and 79%, respectively. Although a significant proportion of patients experienced worsening IBD post-transplantation, the presence or severity of IBD did not influence rPSC or patient survival.

CONCLUSION

Acute cellular rejection and cytomegalovirus mismatch were both identified as independent predictors of rPSC. The impact of steroids and the ideal immunosuppressive regimen for the control of both IBD and PSC post-transplant requires further examination in prospective studies.

Prediction of graft loss and death in patients with primary sclerosing cholangitis

BACKGROUND

The prognosis of patients with primary sclerosing cholangitis (PSC) can be accurately determined using the Mayo Clinic Score (MRS), a mathematical model which predicts patient survival. The purpose of our study was to determine the risk of graft loss and/or death among patients who were listed or transplanted because of PSC.

PATIENTS AND METHODS

We analyzed the data of 52 patients, who were placed on the transplant list due to PSC between January 2000 and November 2008 and either did or did not undergo liver transplantation (OLT). The primary end point (EP1) of the study was the patient death for any cause. The secondary end point (EP2) was recurrence of PSC or appearance of CCC or death related to the primary liver disease after OLT (PSC recurrence). The observation time was 60 months. According to the calculated MRS, patients were divided into 3 groups: group A (MRS < 0.56); group B (0.56 < or = MRS < 1.56), and group C (MRS > 1.56). The analysis was performed using the LIFETEST and PHREG Procedures of the SAS System.

RESULTS

The risk of EP1 occurrence was 2.0 per 1 point of MRS (P < .0006). The risk of EP2 was 2.1 per 1 point of MRS (P < .001). Groups B and C compared with group A showed risks of death of: 0.79 (P = NS) and 6.59 (P < .08), respectively. The percentage of 5-year patient survival rate were 94%, 94%, and 45% according to groups A, B, and C, respectively.

CONCLUSION

The risk of death in patients with MRS > 1.56 was 6.59-fold higher than those with MRS < 0.56. MRS > 1.56 significantly decreased 5 year survival among patients with primary sclerosing cholangitis.

Clinical features of primary sclerosing cholangitis with onset age above 50 years

BACKGROUND

Although there are two peaks in the age distribution of primary sclerosing cholangitis (PSC) in Japan, the clinical differences between the patients with an older or younger onset age have not been reported.

METHODS

We compared clinical features of 18 patients with onset age less than 50 years (younger group) and ten PSC patients with onset age above 50 years (older group).

RESULTS

An association with ulcerative colitis (UC) was recognized in six patients in the younger group and in one in the older group. High serum IgE (>170 IU/ml) was observed more frequently in the older than in the younger group (1/10 vs. 7/8, P = 0.0029). Mean serum IgM tended to be higher in the younger group (198 vs. 119 mg/dl, P = 0.083). More patients received liver transplantation or continuous bile drainage, or developed liver failure or cholangiocellular carcinoma in the younger than in the older group (11/18 vs. 1/10, P = 0.016).

CONCLUSIONS

Older PSC patients have higher IgE, possibly less association with UC, lower IgM, and a better prognosis. The pathogenesis of PSC may be different between older and younger patients.

Recurrence of cholestatic liver disease after living donor liver transplantation

End-stage liver disease, due to cholestatic liver diseases with an autoimmune background such as primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC), is considered a good indication for liver transplantation. Excellent overall patient and graft outcomes, based mostly on the experience from deceased donor liver transplantation (DDLT), have been reported. Due to the limited number of organ donations from deceased donors in most Asian countries, living donor liver transplantation (LDLT) is the mainstream treatment for end-stage liver disease, including that resulting from PBC and PSC. Although the initial experiences with LDLT for PBC and PSC seem satisfactory or comparable to that with DDLT, some aspects, including the timing of transplantation, the risk of recurrent disease, and its long-term clinical implications, require further evaluation. Whether or not the long-term outcomes of LDLT from a biologically related donor are equivalent to that of DDLT requires further observations. The clinical course following LDLT may be affected by the genetic background shared between the recipient and the living related donor.

Present and future therapeutic strategies in non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is found in individuals who do not drink or abuse alcohol and represents a significant health burden for the general community. NAFLD is often associated with one or more features of the metabolic syndrome and has potential for evolution towards non-alcoholic steatohepatitis (NASH), the necro-inflammatory form of liver steatosis. The most worrisome evolutive events in a subgroup of NASH patients include advanced liver fibrosis, cirrhosis, and hepatocellular carcinoma. Pathophysiology of NAFLD/NASH is complex, but studies point to a pre-eminent role of oxidative stress and lipid peroxidation in the liver, including early mitochondrial dysfunction. Changes follow an insulin resistance status with a background of a chronic pro-inflammatory status due to an excess of visceral adiposity. Although no established therapy exists for NAFLD/NASH, potential therapeutic approaches are discussed in this review.

Treatment for autoimmune pancreatitis: consensus on the treatment for patients with autoimmune pancreatitis in Japan

Autoimmune pancreatitis (AIP) has been characterized by unique clinical imaging, immunological findings, and the effectiveness of steroid therapy. A set of clinicopathological criteria for AIP was proposed by the Japan Pancreatic Society in 2002, and AIP has come to be widely recognized among general digestive clinicians. However, the indication of steroid therapy for AIP is still not well established, and furthermore the therapeutic doses and method of administration of steroid therapy is also unclear. Recently, an epidemiological survey of all the treatments used for AIP in Japan was conducted by the Research Committee of Intractable Pancreatic Diseases, and their report "Consensus for a Treatment of Autoimmune Pancreatitis" was produced. In a comparison of the results of steroid therapy and nonsteroid therapy for AIP in relation to the rate of complete remission, the recurrence rate, and the period needed to guarantee complete remission, it was thought that the administration of a steroid should be a standard therapy for AIP. However, if the diagnosis of AIP is still uncertain, steroid therapy should be given with caution. In addition, even when AIP still appears to be possible after a course of steroid therapy, a re-evaluation should be carried out taking pancreatic carcinoma into consideration. An initial steroid dose of 30-40 mg per day is recommended. With continuous and careful observations of the clinical manifestations, laboratory data, and imaging findings after administration of the initial dose of steroid for 2-4 weeks, the quantity of steroid can be reduced gradually to a maintenance dose in 2-3 months, and then reduced to 2.5-5 mg per day after remission. The recommended period of maintenance treatment is still unclear, but the administration of the steroid could be stopped after a period of about 6-12 months of treatment, although the patient should be monitored for clinical manifestations of improvement. In addition, the patient's progress should be followed taking recurrence into consideration. In order to evaluate the effectiveness of steroid therapy, follow-up observations should include biochemical examinations of blood findings such as serum gamma-globulin, IgG, and IgG 4, imaging findings, and clinical manifestations such as jaundice and abdominal discomfort.

Extraintestinal manifestations of inflammatory bowel diseases

Inflammatory bowel diseases are associated with extraintestinal manifestations involving almost every organ system in the body. They occur in approximately 20% to 40% of patients with inflammatory bowel diseases. Immune-related and genetic mechanisms play an important role in the pathogenesis of these complications. Peripheral arthritis, erythema nodosum, and episcleritis respond to the treatment of the underlying intestinal inflammation, whereas axial arthropathy, pyoderma gangrenosum, and uveitis do not. Immunomodulator therapy, particularly with biologic agents has been shown to be effective in treating some of the extraintestinal manifestations. Early recognition and treatment are crucial in preventing major morbidity.

Intrahepatic segmental primary sclerosing cholangitis: report of a case

A 67-year-old woman was referred to our hospital for investigation of epigastric discomfort. Computed tomography (CT) showed dilatation of the intrahepatic bile duct in the left lobe of the liver, endoscopic cholangiography showed complete stenosis of the left main branch of intrahepatic bile duct, and CT during angiography showed decreased portal blood flow to segment 3 of the liver. Based on these findings, we suspected intrahepatic cholangiocarcinoma and performed left lobectomy of the liver. However, pathological examination revealed fibrosis and infiltration of inflammatory lymphoid cells around the stenotic bile duct and periportal area, without any evidence of malignancy. Since these findings were compatible with sclerosing cholangitis and the patient did not have a disorder that would cause secondary sclerosing cholangitis, the final diagnosis was primary sclerosing cholangitis (PSC). It is difficult to distinguish segmental PSC from cholangiocarcinoma; thus we think surgical resection is an appropriate therapeutic and diagnostic procedure for segmental intrahepatic bile duct stenosis.

Ursodeoxycholic acid treatment of vanishing bile duct syndromes

Vanishing bile duct syndromes (VBDS) are characterized by progressive loss of small intrahepatic ducts caused by a variety of different diseases leading to chronic cholestasis, cirrhosis, and premature death from liver failure. The majority of adult patients with VBDS suffer from primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). Ursodeoxycholic acid (UDCA), a hydrophilic dihydroxy bile acid, is the only drug currently approved for the treatment of patients with PBC, and anticholestatic effects have been reported for several other cholestatic syndromes. Several potential mechanisms of action of UDCA have been proposed including stimulation of hepatobiliary secretion, inhibition of apoptosis and protection of cholangiocytes against toxic effects of hydrophobic bile acids.

[Anicteric cholestasis: imaging and diagnostic strategy]

Cholestasis is due to abnormal biliary secretion, from hepatic or extra hepatic causes. The diagnostic strategy of anicteric cholestasis will be discussed, defining hepatic biologic abnormalities, and the role and sequence of imaging techniques based on clinical and biological findings. Main causes will be emphasized and illustrated with different radiological techniques (US, CT and MRI).

Basic immunosuppressive drugs outside solid organ transplantation

Immunosuppressive drugs are the backbone of solid organ transplantation. The introduction of new immunosuppressive drugs led to improved patient and organ survival rates. Nowadays, acute rejection can be reduced to a minimum. Individualization and avoidance of drug-related adverse effects became a new goal to achieve. The potency of immunosuppressive drugs makes them attractive for use in various autoimmune diseases; therefore, the experience on immunosuppressive drugs outside the field of organ transplantation is analysed in this review.

Measurement of parenchymal function and bile duct flow in primary sclerosing cholangitis using dynamic 99mTc-HIDA SPECT

BACKGROUND AND AIM

Primary sclerosing cholangitis is a chronic cholestatic disease characterized by obliterative fibrosis of intrahepatic and/or extrahepatic bile ducts. The unpredictable clinical course of the disease can be relentless, leading to premature death in a large percentage of patients. Prognostic index formulas, the revised Mayo model being the most frequently used, have been developed to predict clinical course and prognosis. The aim of this study was to investigate the potential value of dynamic (99m)Tc-HIDA SPECT in patients with primary sclerosing cholangitis by correlating scintigraphic results with cholangiographic and biochemical findings and prognostic scoring systems used in clinical practice.

METHODS

In 18 patients with primary sclerosing cholangitis, segmental parenchymal and bile duct functions were measured using dynamic (99m)Tc-HIDA SPECT. Quantitative scintigraphic results were compared to cholangiographic findings, as graded by a biliary classification system, the Child-Pugh score and revised Mayo prognostic score, as well as the individual biochemical parameters included in the scoring systems.

RESULTS

In individual segments, scintigraphic quantitative parameters indicative of bile flow showed a statistically significant correlation with the state of the bile-flow path for the respective segments as assessed by the biliary classification system. The revised Mayo score correlated with the scintigraphic quantitative parameters indicative of parenchymal function and bile flow as calculated for the whole liver.

CONCLUSIONS

Dynamic (99m)Tc-HIDA SPECT, capable of assessing different aspects of liver function for the total liver, as well as for individual segments, has potential value in the management of patients with primary sclerosing cholangitis.

Factores predictores de hipertensión portal en los enfermos con colangitis esclerosante primaria

BACKGROUND

Primary sclerosing cholangitis (PSC) is characterized by progressive destruction of bile ducts, which may lead to cirrhosis and portal hypertension. The factors associated with the presence of esophageal varices (EV) and the risk of bleeding have not been well defined.

AIM

To determine the factors associated with the presence of EV and risk of bleeding in a cohort of patients with PSC.

MATERIAL AND METHODS

We analyzed the demographic, biochemical and endoscopic characteristics, and follow-up of 32 patients with a diagnosis of PSC. All patients underwent endoscopic evaluation to determine the presence of EV at diagnosis and annually during follow-up.

RESULTS

There were 24 men (75%) and 8 women (25%). The mean age was 40.2 years (range, 19-66). At diagnosis, none of the patients had a previous history of variceal bleeding and 4 (13%) had EV on endoscopic examination. In bivariate analysis, the factors associated with the presence of EV were: splenomegaly (4/6 vs 0/26; p < 0.001), ascites (2/4 vs 0/24; p < 0.001), thrombocytopenia (96 +/- 27 vs 299 +/- 135 x 10(3), p < 0.001), and hypoalbuminemia (2.4 +/- 0.6 vs 3.5 +/- 0.6 g/dl; p = 0.005). During a mean follow-up period of 7 years (range, 2-15 years), 6 patients developed EV and 7 patients had at least one episode of variceal bleeding. In logistic regression analysis, the factors independently associated with the presence of EV at diagnosis were thrombocytopenia (p = 0.001) and splenomegaly (p = 0.01). The factors associated with variceal bleeding were worsening of liver function (p = 0.01) and splenomegaly (p = 0.02).

CONCLUSIONS

There are noninvasive indicators of portal hypertension that could predict the presence of EV and risk of bleeding in patients with PSC. The presence of thrombocytopenia, splenomegaly or worsening of liver function should be detected in these patients, as they could benefit from endoscopic surveillance.

Sclerosing cholangitis secondary to hepatic artery ligation after abdominal trauma

Several causes have been postulated as responsible for secondary sclerosing cholangitis (SSC), mainly in adults, and, although in very different situations, ischaemia seems to be one of the most important factors. The term 'ischaemic cholangitis' has been used as a collective label for all these ischaemia-induced bile duct lesions. The biliary epithelium is dependent on arterial blood flow, unlike the hepatic parenchyma, which receives a dual blood supply from the hepatic artery and the portal vein. This makes the biliary epithelium very susceptible to changes in arterial blood flow. We present one adolescent patient who developed SSC after abdominal trauma with hepatectomy and ligation of the right hepatic artery. Different factors could have helped in the development of SSC in our patient (septicaemia, bile duct destruction, cholecystectomy) but right hepatic artery ligation seems to be the most important aetiological factor in the development of secondary ischaemic cholangitis.