Endoscopic management of cholangiocarcinoma.

Cholangiocarcinoma constitutes the second most common primary liver cancer after hepatocellular carcinoma. It is particularly prevalent in regions where liver flukes are hyperendemic. Obstructive jaundice is the most common presentation. To evaluate patients suspected for cholangiocarcinoma, endoscopy is becoming more popular. Endoscopy can provide important information especially cholangiogram and tissue diagnosis. Recently, the role of endoscopy has not only been used for diagnosis but also for treatment. In this article, the roles of endoscopy for diagnosis, therapy, and future modality of treatment for cholangiocarcinoma are provided.

Endoscopy in HIV infected patients.

HIV is a very common infection in Thailand, affecting about one million of the population already, with 99,555 persons with full blown AIDS at the end of 1999. The first case of AIDS was reported in Thailand in 1984. Gastrointestinal involvement is very common, the commonest presentations are diarrhea, esophageal symptoms, hepatobiliary symptoms, and weight loss. When the CD4+ T cell count falls below 200, the body becomes highly susceptible to opportunistic infections and neoplasms. Almost all AIDS patients will have GI symptoms at sometime during the course of their illness. This is because the GI tract contains an abundant quantity of lymphoid tissue and is likely to function as a reservoir of HIV infection. In chronic diarrhea cases, apart from other investigations, small bowel biopsy and aspiration may help to find the cause. If oral candidiasis is present, one should keep HIV in mind and look for oral hairy leucoplakia, dysphagia and odynophagia as one-third of patients with AIDS will develop dysphagia or odynophagia in the course of their disease. Those with esophageal candidiasis will usually have oral candidiasis and odynophagia while 18 per cent of the patients will not have oral thrush. CMV esophagitis and HIV ulcer (or idiopathic oesophageal ulcer) are also common. Upper gastrointestinal endoscopy and biopsy are helpful in finding the exact cause of the oesophageal symptoms. Hepatobiliary manifestations are present with jaundice, hepatomegaly, and pain. ERCP is very helpful in diagnosing and classifying these conditions. Papillary stenosis and dominant biliary stricture can be treated by endoscopy but long term results are still poor due to late manifestation of these conditions.

Papillary stenosis in King Chulalongkorn Memorial Hospital: endoscopic findings, treatments and result.

Papillary stenosis usually presents with biliary type abdominal pain, significantly elevated liver enzymes, and cholangiogram revealing dilated common bile duct without stone. In the Western world, endoscopic biliary sphincterotomy is accepted as a standard treatment for papillary stenosis. In Asia, there are only a few reports regarding papillary stenosis. This is a report of our experience on endoscopic biliary sphincterotomy for papillary stenosis in Thai patients. From our ERCP database, twenty-five patients presented with biliary type abdominal pain, elevated liver enzymes and dilated common bile duct by ultrasonography. All of them underwent ERCP for a diagnosis of possible biliary obstruction. Of these 25 cases, seven patients with papillary stenosis were identified. All underwent endoscopic biliary sphincterotomy with or without biliary dilation and stent placement. These patients were followed for clinical improvement and normalization of liver enzymes. Endoscopic biliary sphincterotomy was successful in all patients. One patient required additional biliary dilation and stent placement. All seven patients reported significant improvement of biliary type abdominal pain. Liver enzymes also normalized 3 months after endoscopic treatment. There were no severe complications except one patient who developed post ERCP pancreatitis while another developed minimal bleeding at the sphincterotomy site. Endoscopic biliary sphincterotomy is effective and safe in patients with papillary stenosis. Results of our series are comparable to previous reports from Western countries.