Colangiopatía hipertensiva portal por transformación portal cavernomatosa de origen no cirrótica: a propósito de un caso

La colangiopatía portal hace referencia a anomalías colangiográficas que se producen en pacientes con cavernomatosis portal, siendo progresiva, cursando con enfermedad biliar sintomática y anomalías graves de las vías biliares. Y, representa una complicación infrecuente de la hipertensión portal. Se describe el caso de un hombre de 53 años, con historia de larga data de hipertensión portal nocirrótica y cavernomatosis portal, quien presentó un episodio de enfermedad biliar obstructiva sintomática, y en estudios se documentó tejido fibrótico de extensión periportal ascendente con compresión extrínseca del colédoco distal y dilatación de la vía biliar extra e intrahepática. Por lo que se procedió a colangiopancreatografía retrógrada endoscópica, realizándose tratamiento paliativo, con papilotomía pequeña y colocación de endoprótesis biliar plástica, siendo exitoso por ausencia de complicaciones procedimentales, y mejoría clínica y parámetros bioquímicos. Finalmente, recibiendo de alta con indicación de seguimiento prioritario para recambios periódicos de endoprótesis biliares, y valoración por hepatología. La colangiopatía portal es una entidad rara que debe sospecharse en sujetos con hipertensión portal de origen no-cirrótico, con hallazgos imagenológicos de estenosis, angulaciones o dilataciones segmentarias, su tratamiento debe ser individualizado, y la terapia endoscópica es de elección en enfermedad biliar sintomática.

Portal cholangiopathy refers to cholangiographic abnormalities occurring in patients with portal cavernomatosis, being progressive, presenting with symptomatic biliary disease and severe biliary tract abnormalities. And, it represents an infrequent complication of portal hypertension. We describe the case of a 53-year-old man with a long history of non-cirrhotic portal hypertension and portal cavernomatosis, who presented an episode of symptomatic obstructive biliary disease, and studies documented fibrotic tissue of ascending periportal extension with extrinsic compression of the distal common bile duct and dilatation of the extra and intrahepatic biliary tract. Therefore, endoscopic retrograde cholangiopancreatography was performed, and palliative treatment with small papillotomy and placement of a plastic biliary endoprosthesis was successful due to the absence of procedural complications, and clinical improvement and biochemical parameters. Finally, the patient was discharged with indication of priority follow-up for periodic replacement of biliary stents, and evaluation by hepatology. Portal cholangiopathy is a rare entity that should be suspected in subjects with portal hypertension of non-cirrhotic origin, with imaging findings of stenosis, angulations or segmental dilatations, its treatment should be individualized, and endoscopic therapy is of choice in symptomatic biliary disease.

Pre-operative Non-Invasive Imaging for Neonatal Cholestasis in a Child with Extrahepatic Biliary Atresia

@#Hepatobiliary iminodiacetic acid (HIDA) scintigraphy is a non-invasive, functional imaging of the hepatobiliary system that serves as an adjunct imaging modality for neonatal cholestasis work-up. In view of the urgency to diagnose biliary atresia and restore bile flow through surgery, HIDA scintigraphy could help to distinguish between neonatal cholestasis due to biliary atresia and neonatal hepatitis of various causes. We describe a full-term male infant with jaundice beyond the physiological period in which HIDA scintigraphy showed absent tracer excretion from the biliary system into the intestines up to 5 hours on follow-up imaging. The intraoperative diagnosis confirmed the diagnosis of biliary atresia. The prognosis of the patient with biliary atresia depends on early surgical planning and intervention. Therefore, non-invasive diagnostic tools play an important role in the evaluation of a child with neonatal cholestasis.

Colangite aguda: da tríade de Charcot aos critérios de Tóquio / Acute cholangitis: from Charcot's triad to Tokyo guidelines

O objetivo deste estudo foi revisar as ferramentas diagnósticas e de manejo da colangite aguda, da tríade de Charcot aos critérios de Tóquio. Foi realizada revisão da literatura no PubMed® utili- zando a combinação dos descritores "Tokyo Guideline", "Char- cot's triad" e "Acute cholangitis". A tríade de Charcot foi a pri- meira ferramenta diagnóstica da colangite aguda. Apesar de sua contribuição, foram os critérios de Tóquio a primeira diretriz com evidência clínica para diagnóstico, classificação de severidade e estratégia para o manejo da colangite aguda. A literatura atual busca identificar marcadores de mau prognóstico do paciente, como a procalcitonina, assim como o tempo ideal para a terapia antibiótica e a drenagem biliar. É bem estabelecido o quanto a tríade de Charcot, juntamente dos critérios de Tóquios, contri- buiu para o melhor diagnóstico e manejo da colangite aguda. Todavia, mais estudos são necessários para validação científica dessas diretrizes na prática clínica-cirúrgica.

The objective of this study was to review acute cholangitis diag- nostic and management tools, from Charcot's triad to Tokyo guidelines. The keywords "Tokyo guideline", "Charcot's triad", and "Acute cholangitis" were searched in PUBMED® and used to review the literature. Charcot's triad was the first diagnostic tool in acute cholangitis. Despite its contribution, Tokyo guidelines were the first evidence-based parameters for diagnosis, severity assessment, and strategy for acute cholangitis management. The current literature searches for biomarkers of patient's bad prognostic, such as procalcitonin, as well the optimal timing of antibiotic therapy and biliary drainage. The good contribution Charcot's triad and Tokyo guidelines has made to improved diagnosis and management of acute cholangitis is well-esta- blished. However, further studies are required for scientific vali- dation of these guidelines in clinical-surgical practice.

Novel Non-Surgical Interventions for Benign Inflammatory Biliary Strictures in Infants: A Report of Two Cases and Review of Current Pediatric Literature / 대한소아소화기영양학회지

Benign biliary strictures are uncommon in children. Classically, these cases are managed surgically, however less invasive approaches with interventional radiology and or endoscopy may have similar results and improved safety profiles While benign biliary strictures have been described in literature on several occasions in young children, (most older than 1 year and once in an infant 3 months of age), all reported cases were managed surgically. We present two cases of benign biliary strictures in infants less than 6 months of age that were managed successfully with novel non-invasive procedures and a review of all current pediatric cases reported in the literature. Furthermore, we describe the use of a Rendezvous procedure, which has not been reported as a treatment approach for benign biliary strictures.

Clinical features of cholestatic liver disease of 107 cases / 临床肝胆病杂志

ObjectiveTo investigate the clinical features of cholestatic liver disease (CLD), and to provide a reference for strengthening the diagnosis and treatment of this disease. MethodsA retrospective analysis was performed for the clinical data of 107 patients who were admitted to Chenggong Hospital Affiliated to Xiamen University from January 2015 to December 2017 and were diagnosed with CLD. The t-test was used for comparison of continuous data between groups. ResultsMost patients had the clinical symptoms of weakness, loss of appetite, nausea, abdominal distension, pruritus, and jaundice. According to the site of cholestasis, there were 64 patients (59.8%) with intrahepatic cholestasis and 43 (40.2%) with extrahepatic cholestasis. The cause of the disease was common bile duct stones in 21 patients (19.6%), bile duct parasites in 1 patient (0.9%), primary sclerosing cholangitis in 2 patients (1.9%), primary biliary cirrhosis in 3 patients (2.8%), liver cancer in 8 patients (7.5%), bile duct carcinoma in 5 patients (4.7%), pancreatic cancer in 4 patients (3.7%), pancreatitis in 12 patients (11.2%), viral hepatitis in 28 patients (26.2%), drug-induced liver injury in 11 patients (10.3%), alcoholic hepatitis in 6 patients (5.6%), nonalcoholic fatty liver disease in 4 patients (3.7%), and autoimmune hepatitis in 2 patients (19%). The CLD patients with underlying diseases had a significantly poorer liver function (alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, alkaline phosphatase, bile acid, and total bilirubin) than those with CLD alone (t=-3.44, -2.99, -2.42, -4.39, -3.34, and -2.49, all P＜0.05). Most of the patients achieved good recovery after liver-protecting, transaminase-lowering, and jaundice clearance treatment. The patients with tumors had poor prognosis. ConclusionCLD has various causes, and its clinical features lack specificity. Clinicians should pay enough attention to this disease.

Alerta amarelo: icterícia após duas semanas de vida é uma urgência pediátrica / Yellow alert: icterus after two weeks of life is equal of medical evaluation

A colestase neonatal manifesta-se clinicamente com icterícia, colúria, hipocolia ou acolia fecal. Reveste-se de grande importância, uma vez que requer propedêutica urgente e precisa, com o propósito de definir o diagnóstico e tratamento. Diante de todo recém-nascido cuja icterícia persista além dos 14 dias de vida, impõe-se a dosagem das bilirrubinas (total e fração) e a observação da coloração das fezes e urina. Uma vez confirmada a colestase, é necessário o encaminhamento urgente para umcentro de referência. Para investigação da causa da colestase, o uso de protocolo sistemático é útil para agilizar o diagnóstico. Atresia biliar, uma das principais causas de icterícia colestática, necessita de correção cirúrgica antes dos 60 dias de vida. Tal procedimento mostra-se bem-sucedido em 70 a 80% dos pacientes operados antes dessa idade. O encaminhamento tardio dos pacientes com suspeita de AB constitui um dos principais fatores para o fracasso da correção cirúrgica. Por isso, a divulgação da importância da análise da cor das fezes e da dosagem de bilirrubinas, a partir de campanhas como alerta amarelo, é necessária e deve atingir não apenas os pais, mas também os profissionais da saúde...

Neonatal cholestasis manifests clinically with jaundice, dark urine, fecal acholia or hipocholia. It is of great importance, since it requires urgent and precise propaedeutics to define diagnosis and treatment. Before every newborn whose jaundice persists beyond 14 days of life, it is necessary the dosage of bilirubin (total and fraction) and the color observation of feces and urine. Once confirmed cholestasis, it is required urgent transfer to a referral center. To investigate the cause of cholestasis, the use of systematic protocol is useful to accelerate the diagnosis. Biliary Atresia (BA), a major cause of cholestatic jaundice, requires surgical correction before 60 days of life. This procedure is successful in 70-80% of patients operated before this age.The late referral of patients with suspected BA is one of the main factors for the failure of surgical correction. Therefore,disclosure of the importance of analyzing the color of feces and the determination of bilirubin through campaigns such as yellow alert is required and must reach not only parents, but also health professionals...

A Novel, Fully Covered Laser-Cut Nitinol Stent with Antimigration Properties for Nonresectable Distal Malignant Biliary Obstruction: A Multicenter Feasibility Study

BACKGROUND/AIMS: Stent migration occurs frequently, but the prevention of complications resulting from covered self-expandable metal stents (C-SEMSs) remains unresolved. We prospectively assessed a newly developed C-SEMS, a modified covered Zeo stent (m-CZS), in terms of its antimigration effect. METHODS: Between February 2010 and January 2011, an m-CZS was inserted into 42 patients (31 initial drainage cases and 11 reintervention cases) at a tertiary referral center and three affiliated hospitals. The laser-cut stent was flared for 1.5 cm at both ends, with a 1 cm raised bank located 1 cm in from each flared end. The main outcome of this study was the rate of stent migration, and secondary outcomes were the rate of recurrent biliary obstruction (RBO), the time to RBO, the frequencies of complications, and overall survival. RESULTS: Of the 31 patients with initial drainage, stent migration occurred in four (12.9%, 95% confidence interval, 5.1% to 29.0%), with a mean time of 131 days. RBO occurred in 18 (58%), with a median time to RBO of 107 days. Following previous C-SEMS migration, seven of 10 patients (70%) did not experience m-CZS migration until death. CONCLUSIONS: m-CZSs with antimigration properties effectively, although not completely, prevented stent migration after stent insertion.

Manejo paliativo del cáncer de vesícula biliar irresecable o metastásico: Conclusiones del Consenso Latinoamericano de Manejo del Cáncer de Vesícula Biliar / Palliative treatment for locally advanced or metastatic gallbladder cancer: conclusions of the Latin American Consensus meeting for the management of gallbladder cancer

Gallbladder cancer is a rare disease in Western developed countries, but it is a highly prevalent and lethal disease in Chile and other countries in Latin America. No randomized controlled trials have been performed in gallbladder cancer to establish standard treatments. We therefore performed the first Latin American consensus meeting for the management of gallbladder cancer. In this article we present the conclusions of the panel of experts for the palliative treatment of unresectable or metastatic gallbladder cancer based on a review of the literature, the discussion of the participating experts and the opinion of the assistants. The topics reviewed included: 1.- Gallbladder Cancer and Cholangiocarcinoma -are they the same disease?; 2. - Palliative Chemotherapy: Indications, Drugs and Schedules; 3. - Palliative Radiotherapy; 4.- Palliative Surgery; 5.-Management of Malignant Biliary Obstruction.

Effects of albumin administration in serum liver enzymes of rats in the presence of extrahepatic biliary obstruction / Efeitos da administração de albumina nos níveis séricos de enzimas hepáticas em ratos com obstrução biliar extra-hepática

PURPOSE: To study the influence of albumin on changes of liver function in the extrahepatic biliary obstruction through an experimental model in rats. METHODS: Sixty rats were divided into four groups: Group C (Control): 6 animals. Group M (Fictitious Operation): 18 rats underwent laparotomy and handling of the bile ducts; Groups O (extrahepatic biliary obstruction) and A (Treated with 2 percent albumin): 18 animals in each group underwent ligation of the ductus liver; The animals in groups M, O and A were divided into three subgroups of 6 animals each to be killed in the 7, 14 and 21 days postoperative (POD). Blood was drawn for determination of total bilirubin (TB), indirect bilirubin (IB), direct bilirubin (DB), alkaline phosphatase (ALP), aspartate aminotransferase (AST) and alanine aminotransferase (ALT). RESULTS: On POD 7, BI levels were 4.5 mg / dl in group O and 2.1 mg / dl in group A (p = 0.025). On the 14th POD, the levels of PA were 1185.2 U / l in the group and O 458.3 U / l in group A (p = 0.004). ALT levels were 101.7 U / l in the group O and 75.7 U / l in group A (= 0.037). On POD 21, the levels of ALP were 1069.5 U / l in the group O and 468.3 U / l in group A (p = 0, 004). CONCLUSION: The administration of albumin reduced the serum levels of bilirubin in the 7th day of supplementation.

OBJETIVO: Estudar a influência da albumina em alterações funcionais do fígado na obstrução biliar extra-hepática por meio de um modelo experimental desenvolvido em ratos. MÉTODOS: 60 ratos distribuídos em quatro grupos: Grupo C (Controle): 6 animais. Grupo M (Operação Fictícia): 18 ratos submetidos à laparotomia e manuseio das vias biliares; Grupos O (Obstrução Biliar Extra-hepática) e A (Tratados com albumina a 2 por cento): 18 animais, em cada grupo, submetidos à ligadura do ducto hepático; Os animais dos grupos M, O e A foram distribuídos em três subgrupos de 6 animais cada, para serem mortos nos 7°, 14° e 21° dias pós- operatórios (DPO). Foi colhido sangue para dosagem de bilirrubina total (BT), bilirrubina indireta (BI), bilirrubina direta (BD), fosfatase alcalina (FAL), aspartato aminotransferase (AST) e alanina aminotransferase (ALT). RESULTADOS: no 7º DPO, os níveis de BI foram 4,5 mg/dl no grupo O e 2,1mg/dl no grupo A (p=0,025). No 14º DPO, os níveis de FAL foram 1185,2 U/l no grupo O e 458,3 U/l no grupo A (p=0,004). Os níveis de ALT foram de 101,7 U/l no grupo O e 75,7 U/l no grupo A (=0,037). No 21º DPO, os níveis de FAL foram de 1069,5 U/l no grupo Oe de 468,3 U/l no grupo A (p =0, 004). CONCLUSÃO: a administração de albumina reduziu os níveis séricos de bilirrubina indireta no 7°dia de suplementação.

Initial clinical experience on improved percutaneous transhepatic biliary drainage in the treatment of malignant obstruction of the proximal biliary / 中华放射学杂志

Objective To investigate feasibility and clinical application value of improved percutaneous transhepatic biliary internal-external drainage (PTBIED).Methods Consecutive patients from April 2007 to April 2010 with malignant obstructive jaundice were diagnosed by medical imaging or pathological confirmation whenever possible.The patients with proximal malignant biliary obstruction and intact inferior common bile ducts ＞ 3 cm in length,and a bilirubin of 70 μmol/L or higher,were included in the experimental group.The control group included patients with low malignant biliary obstruction,and those who met the criteria for the experimental group but refused to receive the altered method of PTBIED.The patients underwent traditional PTBIED in control group.The patients in the experimental group received the procedure as following:according to percutaneous transhepatic cholangiography,a biliary external drainage catheter was modified by adding side-holes.Then under fluoroscopic guidance,the loop tip of the modified biliary drainage catheter was positioned in the inferior common hepatic duct/common bile duct,while the additional side-holes were located in the expanded hepatic duct.Technical success rate,complications,hepatic function and white cell count (WBC) were recorded pre- and post-procedure.All patients were followed-up until death.A t-test was used to compare continuous variable data changes,the Chi-square test was used to compare categorical variable data in two groups,and survival time was assessed using the Kaplan-Meier method.Results Forty-six patients were included in the study,with 21 in the experimental group and 25 in the control group.The procedures were successfully performed in all patients in the two groups.There was no procedure-related death in the two groups.Symptoms were improved similarly after procedures in the two groups.The mean quantity of drained bile per day [experimental group (521 +136) ml/d,control group (606 + 159 ) ml/d,t =1.930,P ＞ 0.05],decrease of the serum total bilirubin after the procedures [ experimental group (87 ± 51 ) μmol/L,control group( 105 ± 66 ) μmol/L ( t =1.061,P ＞ 0.05 ) ] and the median survival time ( experimental group 7.7 months,control group 6.9 months,x2 =0.610,P ＞0.05 ) of the patients showed no statistically significant difference between two groups.The mean WBC amount of patients was higher after the traditional procedure [ ( 10.9 ±5.2) × 109/L] than before the procedure [ (7.8 ±2.9) × 109/L] in the control group ( t =3.606,P ＜ 0.05 ),but the converse change occurred in the experimental group [ pre-procedure (8.2 ± 3.4) × 109/L ],post-procedure [ (7.4 ± 2.6) × 109/L] ( t =2.649,P ＜ 0.05 ).No reflux of duodenal juice was observed in all patients of the experimental group,and 1 patient had infection of biliary tract.The reflux was observed in 11 patients of the control group after conventional PTBIED.Of them,8 patients had infection of biliary tract.Incidence rate of infection of biliary tract in the control group was higher than that in the experimental group( x2 =5.381,P ＜ 0.05 ).Conclusions Improved PTBIED is convenient and feasible,and compared with traditional PTBIED,it can reduce the complications of infection of biliary tract.

Influence of glutamine on morphological and functional changes of liver in the presence of extrahepatic biliary obstruction in rats / Influência da glutamina em alterações funcionais e morfológicas do fígado na vigência de obstrução biliar extra-hepática em ratos

PURPOSE: To study the influence of glutamine on functional and morphological changes of liver in the extrahepatic biliary obstruction through an experimental model in rats. METHODS: Seventy Wistar rats were divided into four groups: control (group C) fictitious operation, (group FO), submitted to laparotomy with handling of bile ducts, but without hepatic duct ligation, (group EBO) submitted to laparotomy and hepatic duct ligation, one of them submitted to supplementation with glutamine 2 percent (group G). The control group consisted of 6 animals. The animals from groups FO, EBO and G were divided into three groups consisting of 6 animals each, being sacrificed at 7, 14 and 21 days after operation, respectively. Blood samples were collected for biochemical analysis and a fragment of liver tissue was collected from the middle lobe for histological analysis. RESULTS: Both for biochemical analysis (BT, aspartate and alanine aminotransferase AST, ALT and alkaline phosphatase FAL) and for histopathological changes (fibrosis, portal inflammation, parenchymal inflammation, hepatocytic changes and duct proliferation), no statistical difference between groups submitted to extrahepatic biliary obstruction (EBO) with and without treatment with glutamine (G) was observed. CONCLUSION: Glutamine supplementation did not alter the prognosis of liver enzymes and histopathological changes in animals submitted to extrahepatic biliary obstruction.

OBJETIVO: Estudar a influência da glutamina em alterações funcionais e morfológicas do fígado na obstrução biliar extra-hepática por meio de um modelo experimental desenvolvido em ratos. MÉTODOS: Setenta ratos Wistar distribuídos em quatro grupos: controle (grupo C); operação fictícia (grupo OF), submetido à laparotomia com manuseio das vias biliares, mas sem ligadura do ducto hepático; (grupo OBE), submetido à laparotomia exploradora e ligadura do ducto hepático, sendo um deles submetido à suplementação com glutamina a 2 por cento (grupo G). O grupo controle era composto por seis animais. Os animais dos grupos OF, OBE e G foram divididos em três grupos compostos por seis animais cada e que foram sacrificados no 7°, 14° e 21° dias após a operação, respectivamente. Foi colhido sangue para análise bioquímica e um fragmento de tecido hepático do lobo médio para estudo histológico. RESULTADOS: Tanto em relação à analise bioquímica (BT, aspartate and alanine aminotransferase AST, ALT e FAL) quanto em relação às alterações histopatológicas (fibrose, inflamação portal, inflamação parenquimatosa, alterações hepatocíticas e proliferação de ducto), não houve diferença estatística entre os grupos submetido a obstrução biliar extra-hepática sem (OBE) e com tratamento com glutamina (G). CONCLUSÃO: A suplementação com glutamina não alterou o prognóstico em relação às enzimas hepáticas e alterações histopatológicas nos animais submetidos à obstrução biliar extra-hepática.

Estudo prospectivo e comparativo do escovado obtido pela CPER à ecoendoscopia associada à punção aspirativa com agulha fina (EE-PAAF) no diagnóstico diferencial das estenoses biliares / Prospective comparative study of ERCP brush cytology and EUS-FNA for the diferential diagnosis of biliary strictures

OBJETIVO: Avaliar o desempenho diagnóstico da citologia obtida pela CPER, aquele obtido pela EE-PAAF e a concordância entre patologistas gerais (PG) e especialistas (PE) em pacientes com estenose biliar. MÉTODOS: Incluímos pacientes com estenose biliar identificados pela CPER. A EE-PAAF foi realizada apenas em áreas com efeito de massa ou da parede espessada do ducto biliar. O padrão-ouro foi a cirurgia, histologia e/ou o seguimento. As amostras teciduais foram consideradas: malignas, suspeitas, atípicas, insuficientes ou benignas. Os espécimes obtidos por cada método foi interpretado (cego) por um PG e outro PE. RESULTADO: 46 pacientes foram incluídos (37 malignos e 9 benignos). O diagnóstico final foi de tumor pancreático (26), biliar (11), pancreatite crônica (8) e estenose inflamatória do ducto biliar (1). Sensibilidade e acurácia da CPER foram 43,2 por cento e 52,2 por cento para o PG e 51,4 por cento e 58,7 por cento para o PE. Sensibilidade e acurácia da EE-PAAF foi 52,8 por cento e 58,5 por cento para o PG e 69,4 por cento e 73,2 por cento para o PE. A combinação entre a CPER e EE-PAAF demonstrou maior sensibilidade e acurácia para ambos PG (64,9 por cento e 69,6 por cento) e PE (83,8 por cento e 84,8 por cento), respectivamente. CONCLUSÃO: A citologia obtida pelo escovado da via biliar durante a CPER e as amostras teciduais colhidas pela EE-PAAF tem rendimento semelhante para o diagnóstico das estenoses biliares. No entanto, a combinação dos métodos resulta em uma maior acurácia. Além disso, espera-se que a interpretação das amostras ocorra com maior precisão pelo PE se comparado ao PG.

OBJECTIVE: To evaluate and to compare the diagnostic yield of ERCP brush cytology (ERCP) and EUS-FNA in patients with biliary strictures and evaluates the agreement between general pathologists (GP) and expert GI pathologists (GIP) in the final diagnosis of biliary strictures. METHODS: Patients with biliary strictures documented by ERCP were included. Brush cytology was performed and during EUS, only visible mass lesions or localized bile duct wall thickening were aspirated. The gold standard method for diagnosis was surgical histology and/or follow-up. Tissue sampling results were: malignant, suspicious, atypical, insufficiently or benign. Specimens were interpreted by GP and GIP, blinded for prior tests results. RESULTS: 46 patients were included. Final diagnosis was malignancy in 37 (26 pancreatic - 11 biliary) and benign in 9 (8 chronic pancreatitis - 1 common bile duct inflammatory stricture). Sensitivity and accuracy for ERCP brush cytology were 43.2 percent and 52.2 percent for GP and 51.4 percent and 58.7 percent for GIP. Sensitivity and accuracy for EUS-FNA were 52.8 percent and 58.5 percent, respectively for GP and 69.4 percent e 73.2 percent for GIP. In comparison, the combination of brush cytology and EUS-FNA demonstrated higher sensitivity and accuracy for both GP (64.9 percent and 69.6 percent, respectively) and GIP (83.8 percent and 84.8 percent, respectively) and improved agreement with final diagnosis for both (mostly for GIP). CONCLUSION: Both, ERCP brush cytology and EUS-FNA has a similar yield for the diagnosis of biliary strictures. However, the combination of these methods results in an improved diagnostic accuracy. In addition, GIP might be expected to interpret specimens with greater accuracy than GP.

A study of impact of stent implantation in distal common bile duct on duodenal-biliary reflux / 中华放射学杂志

Objective This study aimed to investigate the incidence and the cause for duodenalbiliary reflux and reflux cholangitis after metallic stent placement in distal common bile duct Methods After percutaneous transhepatic bile duct puncture and biliary outside drainage was performed, 16 cases with malignant distal biliary stricture underwent metallic stent placement in distal common bile duct Before stent placement, the routine laboratory studies including leukocyte, neutrophil percentage and the levels of total bilirubin and direct bilirubin in blood were performed for all patients. Two to five days [ an average of (3.3 ±0. 9) days ] after stent implantation, the above indexes were tested again, and 1 ml of water containing 185 MBq of 99Tcm-DTPA was given orally before extubation, then 99Tcm radioactivity in the bile was detected 2 hours later. For the measurement data obtained from the experiment, t test or Wilcoxon signed rank test was adopted to compare them, and P ＜ 0. 05 was considered to be statistically different Results In 14 cases, radioactivity was successfully detected in the bile 2-5 days after stent implantation. Twelve of them was detected to have radioactivity in the bile 2 hours before extubation with duodenal-biliary reflux. The technetium count in the bile accounted for 1.82% of the total intake dose. There was no radioactivity in the bile in 2 cases. In 14 patients, there were no symptoms of cholangitis such as high fever, chills, increased jaundice, and so on after stent implantation. The mean of white blood cell count was (7.59 t2. 62) × 109/L, and the median of neutrophil percentage was 0. 74. Compared with those before stent implantation, the difference did not reach statistical significance ( t = 0. 423, Z = 1. 036, P ＞ 0. 05 ).After stent implantation, the median of total bilirubin and direct bilirubin were significantly lower, which were 92. 2 and 74. 3 μmol/L. Compared with those before stenting,the difference was statistically significant (Z= -3. 170, -3. 170, P ＜0.05). Conclusions There is a high incidence of duodenal-biliary reflux after stent implantation in distal common bile duct in the early stage. However, there is no simultaneous cholangitis caused by duodenal-biliary reflux.

Hepatoprotective effect of water soluble extract of Coleus barbatus on cholestasis on young rats / Efeito hepatoprotetor do extrato aquoso de Coleus barbatus na colestase em ratos jovens

PURPOSE: To test the effects of water extract of Coleus barbatus (WEB) on liver damage in biliary obstruction in young rats. METHODS: Forty 21 day-old male Wistar rats were divided into four groups of ten 21 day old (P21) submitted to sham or actual operation (S or L) combined with WEB or Water (B or A). At P48 pentobarbital sleeping time (ST) was measured. At P49 they were submitted to euthanasia to determine of serum activities of aspartate aminotransferase (AST) and alanine aminotransferase (ALT), liver wet weight (PFF) and, on hepatic histological slides, the frequency of mitoses (FM), the number of necrotic areas (NN), intensity of fibrosis (IF) and intensity of ductal proliferation (IPD). Two Way ANOVA, the S.N.K. test and the Wilcoxon test for paired multiple comparisons were employed to study the effects of cholestasis and those of EAB and their interactions. The Pearson's coefficient of linear correlation of between paired histological variables separately for the groups LA and LD was determined. The test results were considered statistically significant when the p of alpha error <0.05. RESULTS: Cholestasis increased the TS, ALT, AST, PFF, MI, NN, IF and IPD. The EAB decreased the TS and IM in the animals without cholestasis (sham operated animals). The EAB decreased the TS, ALT, AST, PFF, MI, NN and IF of the cholestatic animals. In the LA group there was a positive correlation between the IPD and the IF, a negative correlation between the IPD and the FM and a negative correlation between the IF and the FM. In the LD group there was a negative correlation between the NN and the IPD. CONCLUSIONS: In the absence of cholestasis the EAB reduces the pentobarbital sleeping time and decreases the frequency of mitoses. The EAB has a hepatoprotective effect on the biliary cirrhosis secondary to extra-hepatic biliary obstruction.

OBJETIVO: Testar os efeitos do extrato aquoso de Coleus barbatus (EAB) na cirrose biliar secundária por obstrução das vias biliares extra-hepáticas em ratos jovens. MÉTODOS: Quarenta ratos Wistar machos com 21 dias de vida (P21), foram distribuídos em quatro grupos de 10 animais, submetidos a operação simulada ou dupla ligadura e ressecção do ducto biliar (S ou L) combinados EAB e a Água (B ou A). No P48, foi medido o tempo de sono com o pentobarbital (TS). No P49, foram submetidos a eutanásia para a determinação das atividades séricas do aspartato aminotransferase (AST) e da alanina aminotransferases (ALT); após a eutanásia foram avaliados o peso fresco do fígado (PFF) e, em cortes histológicos do fígado, a freqüência de mitoses (FM), o número de áreas de necrose (NN), a intensidade da fibrose (IF) e da proliferação ductal (IPD). Os efeitos da colestase, os do EAB e suas interações foram testados pela ANOVA com dois fatores, e as comparações múltiplas pareadas foram realizadas pelo teste de S.N.K ou teste de Wilcoxon. Também foi determinada a correlação linear de Pearson entre as variáveis histológicas duas a duas separadamente para os grupos LA e LD. O nível de significância estatística para os vários testes foi de p do erro alfa <0,05. RESULTADOS: A colestase aumentou significativamente o TS, a ALT, a AST, o PFF, a MI, o NN, a IF e a IPD. O EAB diminuiu o TS e a IM nos animais sem colestase (operação simulada). O EAB diminuiu o TS, a ALT, a AST, o PFF, a MI, o NN e IF na colestase. No grupo LA houve correlação positiva entre a IPD e a IF, correlação negativa entre a IPD e a FM e correlação negativa entre a IF a FM. No grupo LD houve correlação negativa entre o NN e a IPD. CONCLUSÕES: Na ausência de colestase o EAB encurta o tempo de sono e diminui a freqüência de mitoses. O EAB apresenta efeito hepatoprotetor no modelo de cirrose biliar secundária a obstrução biliar extra-hepática.

Placement of a Covered Self-expandable Nitinol Stent for Bile Duct Stricture that was Caused by Ischemic Injury after Transcatheter Arterial Chemoembolization in a Patient with Hepatocellular Carcinoma: A Case Report

The authors report here on a case of focal stricture in the common hepatic duct that was caused by ischemic bile duct injury after repeat TACE procedures for hepatocellular carcinoma, and the patient was successfully treated with a covered self-expandable nitinol stent.