Íleo biliar: reporte de casos / GALLSTONE ILEUS: CASES REPORT

El íleo biliar se define como una obstrucción intestinal mecánica secundaria a la presencia de un cálculo biliar. Menos del 1% de los casos de obstrucción intestinal se derivan de esta etiología. La causa más frecuente es la impactación del cálculo en el íleon, tras su paso por una fístula bilioentérica. Es una complicación rara y potencialmente grave de la colelitiasis. Esta patología se presenta más en adultos mayores, la edad promedio en la que se presenta es entre los 60 y 84 años, afectando principalmente al sexo femenino, atribuido a la mayor frecuencia de patología biliar en dicho sexo. Presenta una alta morbimortalidad, principalmente por la dificultad y la demora diagnóstica.

Gallstone ileus is defined as a mechanical intestinal obstruction secondary to the presence of a gallstone. Less than 1% of cases of intestinal obstruction are derived from this etiology. Te most frequent cause is the impaction of the stone in the ileum, after passing through a bilioenteric fistula. It is a rare and potentially serious complication of cholelithiasis. Tis pathology occurs more in the elderly, the average age at which it occurs is between 60 and 84 years, mainly affecting the female sex, attributed to the higher frequency of biliary pathology in said sex. It presents a high morbidity and mortality, mainly due to the difficulty and the diagnostic delay

Cirugia biliar en época de pandemia Experiencia del Hospital de Clínicas "Pte. Nicolás Avellaneda" - (Tucumán-Argentina). / BILIARY SURGERY IN A TIME OF PANDEMIC AT THE CLINICAL HOSPITAL "Pte. NICOLAS AVELLANEDA" TUCUMAN, ARGENTINA

Antecedentes: La rápida diseminación mundial de la enfermedad COVID-19 llevó a declarar la Emergencia Sanitaria, en Argentina se decretó el Aislamiento Social Preventivo y Obligatorio el 20 de Marzo, siguiendo con estos lineamientos Tucumán tuvo que adaptarse reestructurando su Sistema Provincial de Salud, quedando el Hospital de Clínicas Pte. Nicolás Avellaneda, como único hospital polivalente para patologías prevalentes. Objetivo: Mostrar el manejo quirúrgico integral mininvasivo de la patología biliar (laparoscópico, endoscópico, percutáneo y combinado), con plena vigencia de la CMA en este momento de Pandemia, durante el periodo del 20 de Marzo al 29 de Mayo del 2020. Material y métodos: Estudio descriptivo, prospectivo de corte transversal, de la patología quirúrgica biliar a quienes se le realizó Cribado Epidemiológico, exámenes preoperatorios, de ser necesaria una Tomografía Computada de Tórax; con Consentimiento Informado. Resultados: En el periodo estudiado, en el contexto de la pandemia se realizaron 51 intervenciones de la vía biliar; las vías de abordaje de elección fueron de cuatros tipos, según el orden de frecuencia: laparoscópico 65%, combinado 25%, endoscópico 8% y percutáneo 2%, con la modalidad de CMA (Cirugía Mayor Ambulatoria) se realizó 20% y 80% con internación hospitalaria, de los cuales tuvieron un promedio de un día y medio de estadía postoperatorio. Conclusión: La aparición de la Pandemia nos dió la oportunidad de incorporar nuevas técnicas mininvasivas y fortalecer la CMA. Para poder realizar esta labor, es necesario priorizar la seguridad en el entorno de trabajo y la atención de los pacientes.

Health Emergency, in Argentina Preventive and Mandatory Social Isolation was decreed on March 20, following these guidelines Tucumán had to restructure its Provincial Health System, leaving the Hospital Clinicas Pte. Nicolás Avellaneda, as the only multipurpose hospital for prevalent pathologies. Objective: To show the comprehensive minimally invasive surgical management of biliary pathology (laparoscopic, endoscopic, percutaneous, and combined), with full effect of the CMA at this time of the Pandemic, during the period from March 20 to May 29, 2020. Material and Methods: Descriptive, prospective, cross-sectional study of biliary surgical pathology for those who underwent Epidemiological Screening, preoperative examinations, if necessary, a Computed Tomography of the Thorax; with Informed Consent. Results: In the period studied, 51 bile duct problems were performed in the context of the pandemic; the approach routes of choice were of four types, according to the order of frequency: laparoscopic 65%, combined 25%, endoscopic 8% and percutaneous 2%, with the flexibility of CMA (Major Ambulatory Surgery) performed 20% and 80% with hospitalization, of which they had an average of one and a half days of postoperative stay. Conclusion: The appearance of the Pandemic gave us the opportunity to incorporate new minimally invasive techniques and strengthen the CMA. In order to carry out this work, it is necessary to prioritize safety in the work environment and patient care

Diagnostic and therapeutic cholangioscopy in biliary diseases: a prospective study in Peru / Uso diagnóstico y terapéutico de la colangioscopía en enfermedades de la vía biliar: un estudio prospectivo en Perú

Introduction: Cholangioscopy is a test that allows the evaluation of the biliary epithelium. It is used for diagnosis and management of biliary diseases. Objectives: Determine the success rate of complete removal of difficult stones with the use of laser lithotripsy through cholangioscopy as well as its complications. Determine the visual impression accuracy of bile duct injuries. Materials and methods: This is a prospective and descriptive study. We included 39 patients between July 2016 and July 2017 with diagnosis of difficult stones in the biliary tract and indeterminate stenosis of the biliary tract that were submitted to cholangioscopy. Results: Success rate of complete removal of difficult stones was 65.3%, there was one complication. Two laser sessions were required in 4 of the 17 patients who obtained complete removal of the stones. The visual impression accuracy of lesions in the bile duct to determine malignancy coincided in all cases with the final diagnosis of the patient. Conclusions: Laser lithotripsy allows a safe and effective treatment of the difficult stones of the bile duct. Precession of visual impression of lesions in the bile duct is very high.

Introducción: La colangioscopía es un examen que permite evaluar la luz biliar, el epitelio biliar y sirve para diagnóstico y manejo de enfermedades de la vía biliar. Objetivos: Determinar la tasa de éxito de remoción completa de cálculos difíciles con el uso de litotripcia con láser a través de la colangioscopía asi como las complicaciones de ésta. Determinar la precisión de impresión visual de lesiones de la vía bilar. Materiales y métodos: Estudio prospectivo, descriptivo. Se incluyeron a 39 pacientes entre Julio 2016 a Julio 2017 con diagnóstico de cálculo difícil en la vía biliar y estenosis indeterminada de la vía biliar que fueron sometidos a colangioscopía. Resultados: La tasa de éxito de remoción completa de cálculos difíciles fue de 65,3% con una complicación. Se requirió de dos sesiones con láser en 4 de los 17 pacientes que obtuvieron remoción completa de cálculos. La precisión de impresión visual de lesiones en la vía biliar para determinar malignidad coincidió en todos los casos con el diagnóstico final del paciente. Conclusiones: La colangioscopía con uso de litotripcia con láser permite un tratamiento seguro y eficaz en los cálculos difíciles de la vía biliar. La precesión de la impresión visual de lesiones en la vía biliar es muy alta.

Allopurinol-induced DRESS syndrome mimicking biliary obstruction

An 84-year-old man was admitted to our hospital with fever, jaundice, and itching. He had been diagnosed previously with chronic renal failure and diabetes, and had been taking allopurinol medication for 2 months. A physical examination revealed that he had a fever (38.8degrees C), jaundice, and a generalized maculopapular rash. Azotemia, eosinophilia, atypical lymphocytosis, elevation of liver enzymes, and hyperbilirubinemia were detected by blood analysis. Magnetic resonance cholangiography revealed multiple cysts similar to choledochal cysts in the liver along the biliary tree. Obstructive jaundice was suspected clinically, and so an endoscopic ultrasound examination was performed, which ruled out a diagnosis of obstructive jaundice. The patient was diagnosed with DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome due to allopurinol. Allopurinol treatment was stopped and steroid treatment was started. The patient died from cardiac arrest on day 15 following admission.

Diagnosis of Proximal Biliary Strictures: Role of serum bilirubin, alkaline phosphatase and abdominal ultrasound

To determine the role of serum bilirubin, alkaline phosphatase and abdominal ultrasound in the diagnosis of proximal biliary strictures. Cross sectional Place and Duration: Surgical Unit IV, Civil Hospital Karachi, from Jan 2007 to August 2008. A total of 407 patients with obstruction of the biliary tree on ultrasound and raised serum levels of alkaline phosphatase had ERCP performed on them. Serum bilirubin and alkaline phosphatase levels were recorded prior to the procedure. A total of 75 patients with strictures on ERCP were included in the study. Jaundice and abdominal pain were present in 68 [90.6%] and 41 [54.6%] of the total 75 patients respectively. A statistically significant difference was present in the mean bilirubin levels of different stricture groups [p=.024]]. Receiver Operator Curve analysis of serum bilirubin level of 19.2gm/dl showed a sensitivity of 43% and specificity of 77% with area under curve= 0.6. Abdominal ultrasound was found to be 31.8% sensitive and 79.2% specific in predicting the presence of proximal biliary strictures. Serum levels of total bilirubin and alkaline phosphatase and abdominal ultrasound have minor role in the diagnosis of proximal biliary strictures

Fístula colecistocutânea espontânea:uma rara complicação da doença calculosa da vesícula biliar / Spontaneous cholecystocutaneous fistula: a rare complication of gallbladder disease

Introdução: As fístulas colecistocutâneas são complicações infrequentes decorrentes de processos inflamatórios ou infecciosos que ocorrem envolvendo a vesícula biliar ou vias biliares incluindo colédoco e ducto cístico. O primeiro relato data de 1640 por Thilesus, e sua incidência vem diminuindo provavelmente devido à melhora dos métodos diagnósticos de imagem e tratamentos medicamentosos. Relato de caso: Relatamos aqui um caso de um paciente do sexo masculino, de 63 anos de idade, que apresentou como queixa inicial uma dor em hipocôndrio direito do tipo cólica, há cerca de quatro meses, que evoluiu com abscesso local, drenado em outro serviço. Seguiu-se à drenagem débito bilioso persistente. O paciente foi submetido à colangiopancreatografia retrógrada endoscópica com retirada de múltiplos cálculos do colédoco. Após 30 dias o paciente foi operado, sendo realizada colecistectomia com exploração radiológica das vias biliares que evidenciou normalidade das vias biliares intra e extra-hepáticas, obstrução do ducto cístico, estenose de colédoco proximal de cerca de dois centímetros e ausência de cálculos biliares. Realizou-se ainda a ressecção da porção estenosada do colédoco com anastomose primária término-terminal e drenagem a Kher. O paciente evoluiu com fístula biliar pós-operatória orientada por dreno cavitário, evoluindo com baixo débito de cerca de 150 mililitros até o 15º pós-operatório. Discussão: As fístulas colecistocutâneas são uma complicação cada vez mais rara de processos inflamatórios ou infecciosos do trato colecistobiliar, os quais exigem tratamento cirúrgico efetivo envolvendo a colecistectomia com reestabelecimento do trajeto fisiológico de drenagem biliar.

Introduction: The cholecystocutaneous fistulae are unusual complications resulting from infectious or inflammatory processes that occur involving the gallbladder or biliary tract, including choledochal and cystic duct. The first report dates from 1640 by Thilesus, and its incidence has decreased due to improved diagnostic methods for image and drug treatments. Case report: We report a case of a 63 years old male patient who presented an initial complaint of pain in the right hypochondrium, type colic, for about four months, who developed local abscess, drained in another service. Following, there was persistent bilious drainage flow. The patient underwent endoscopic retrograde cholangiopancreatography with the withdrawal of multiple choledochal gallbladder. After 30 days the patient was operated with cholecystectomy performed, with the usage of radiological exploration of the biliary tract, which showed normal intra and extra-hepatic bile ducts, obstruction of the cystic duct, stenosis of proximal choledochal of about two centimeters and absence of gallstones. There was also the resection of the portion of choledochal stenosis with primary end-to-end anastomosis and drainage to Khera. The patient evolved with postoperative biliary fistula guided by drain cavity, evolving with low debt of about 150 milliliters to 15 postoperatively. Discussion: The cholecystocutaneous fistula is an increasingly rare complication of infectious or inflammatory processes of biliary tract, which require surgical treatment with cholecystectomy involving the effective re-establishment of the physiological pathway of bile drainage.

Efecto del tamaño de la incisión en la gravedad de la lesin de la vía biliar iatrogénica posterior a colecistectomía abierta / Association between wound size after open cholecystectomy with severity of iatrogenic biliary tract lesions

Antecedentes: La lesión transoperatoria de la vía biliar durante la colecistectomía abierta y laparoscópica es un evento catastrófico que se asocia con morbilidad y mortalidad significativas. El objetivo fue documentar si el tamaño de la incisión en colecistectomía abierta está asociado a lesiones más complejas de la vía biliar. Métodos: Estudio de cohorte prospectivo de marzo de 2006 a febrero de 2007. Se incluyeron 66 pacientes con lesiones de la vía biliar posterior a colecistectomía abierta. Se analizó el tamaño de la incisión. Resultados: Se incluyeron 66 pacientes, 70% del sexo femenino, con un promedio de edad de 44 años. El 70% fue tratado por colecistitis aguda. La mayoría tuvo sobrepeso o sufría diferentes grados de obesidad. En 76% de los casos, la lesión no fue advertida durante el procedimiento quirúrgico primario. Todos los pacientes con lesión de vía biliar grave (Strasberg E-3 y E-4) tuvieron incisiones menores a 10 cm de longitud. El tamaño de la incisión se asoció con lesiones inadvertidas (p=0.000), así como con el grado de lesión (p=0.000). No pudo demostrarse asociación estadísticamente significativa entre lesiones de la vía biliar y colecistectomía electiva o urgente, e incisión quirúrgica media o subcostal para la colecistectomía. Conclusiones: Nuestros hallazgos sugieren que el acceso quirúrgico menor durante la colecistectomía abierta puede ser un factor de riesgo, ya que incisiones pequeñas se asociaron con lesiones de la vía biliar más graves e imposibilidad para reconocer este daño durante el procedimiento. Sugerimos cumplir estrictamente los principios quirúrgicos de una adecuada exposición durante la colecistectomía abierta como medida para prevenir lesiones de la vía biliar.

BACKGROUND: Transoperative biliary tract injury during open or laparoscopic cholecystectomy is a catastrophic event associated with significant morbidity and mortality. Our objective was to determine if wound size during open cholecystectomy is associated with more complex biliary tract injuries. METHODS: Prospective cohort study performed between March 2006 and February 2007. Sixty-six patients with biliary tract injuries after open cholecystectomy were included. Wound size was analyzed. RESULTS: Sixty six patients were included, 70% were female with a median age of 44. Seventy four percent were treated for acute cholecystitis. Most participants were overweight or had various degrees of obesity. Biliary tract injuries were not recognized during the primary surgical procedure in 76% of cases. All patients with severe biliary tract injuries (Strasberg E-3 and E-4) had a wound size less than 10 cm in length. Wound size was associated with unrecognized injuries (p=0.000), as well as with injury severity (p=0.000). We were notable to demonstrate a statistically significant association between biliary tract injuries and elective or emergency surgical procedures and midline or subcostal surgical incision for cholecystectomy. CONCLUSIONS: Our findings suggest that minor surgical access during open cholecystectomy may constitute a risk factor since smaller incisions were associated with more severe biliary tract injuries and an inability to observe this damage during the surgical procedure. We suggest to adhere strictly to the guidelines of an adequate surgical exposure during open cholecystectomy to prevent biliary tract injuries.

Manejo percutáneo de la patología benigna de la vía biliar principal por cirujanos: experiencia en una sección de cirugía hepato bilio pancreática / Percutaneous management of the benign pathology of the main biliary tract: experience in a section of pancreatic and hepatobiliary surgery

Antecedentes: los procedimientos percutáneos biliares (PPB) han mostrado ser efectivos en el manejo de la patología benigna de la vía biliar. Objetivo: mostrar la experiencia con los PPB en un sector especializado en Cirugía Hepato-Bilio-Pancreática. Lugar de aplicación: institución privada de atención terciaria. Diseño: serie de casos, descritivo. Población: se evaluaron 84 pacientes tratados con PPB por patología benigna de la vía biliar entre enero de 1989 y enero de 2002. Resultado: diagnósticos: litiasis de la vía biliar principal 21 casos, estenosis por lesiones quirúrgicas de vía biliar (LQVB) 29 y otras estenosis benignas de vía biliar 34. Indicaciones: colangitis aguda 45, prurito 11, alto riesgo quirúrgico 10, fracasos o contraindicacciones de la vía endoscópica9, pre-trasplante hepático 12 y otros 3. procedimientos realizados (n=141): f=drenajes percutáneos 96, dilatación de estenosis 27, litotomía percutánea 12, colocación de endoprótesis 5 y biopsia 1. Efectividad: colangitis 94,8%, litiasis 100%, dilatación de estenosis por LQVB 50% y dilatación de otras estenosis benignas de la vía biliar 92%. Complicaciones: total 32 (38,1). Mortalidad hospitalaria 3 (3,6%). Conclusiones: 1. En la colangitis aguda el drenaje fue un método efectivo para descomprimir la vía biliar, permitiendo realizar en forma electiva el tratamiento definitivo de la patología. 2. En los pacientes con alto riesgo o con patologías complejas el acceso percutáneo permitió resolver la patología biliar obstructiva. 3. Los resultados de la dilatación percutánea de las estenosis biliares estuvieron relacinados con la etiología de las mismas.

Hepatic abscesses at the University Hospital of the West Indies. A 24-year autopsy review

A retrospective review of all hepatic abscesses identified at autopsy over the 24-year period 1977-2000 at the University Hospital of the West Indies (UHWI), Kingston, Jamaica, was conducted. Post mortem and microbiology records were reviewed. Data collected included age, gender, predisposing factors, organisms isolated, number of abscesses and associated conditions, such as diabetes mellitus. Data for the adults was analyzed separately. Thirty-nine cases of pyogenic abscesses were identified from 7480 post-mortems. Thirty-three occurred in adults of mean age 59.5 years. Sixty per cent of the abscesses were solitary. Biliary tract disease was the predisposing factor in 33 of cases. Six per cent were cryptogenic: 11/33 patients were diabetic and these were significantly older than non-diabetics (p < 0.014) Klebsiella pneumoniae was the most common organism isolated from diabetics (6.9). Only 2/33 abscesses were diagnosed ante-mortem. The abscesses in children were more frequently multiple and associated with extra-abdominal infection. Gram positive cocci were the commonly isolated organisms in children. There were no cases of amoebic abscess. The prevalence of hepatic abscess was low. Diabetes mellitus was a significant contributing factor. A high index of clinical suspicion is therefore warranted particularly in elderly diabetics

Colangiopancreatografia por resonancia magnética: estudio comparativo con la coloangiografía directa / Magnetic resonance cholangiopancreatography: comparative study with direct cholangiography

Magnetic Resonance Cholangiopancreatography (MRCP) is an emergent non invasive diagnostic technique for the study of pancreaticobiliary system. Following the contraindications of traditional Magnetic Resonance, the MRCP is safe for the patient. Images can be obtained without administration of any contrast and not using Rx. The objective of this study is to evaluate the sensitivity and the specificity of MRCP respect direct cholangiography ([endoscopic retrograde cholangiography (ERCP) and percutaneous transhepatic cholangiography (PTC)]. Forty one patients older than 60 years old were included, 19 male and 22 female, 73.5 median age. All of them have clinical diagnosis of obstructive jaundice. The patients were tested with MRCP first, and blinded of this results a direct cholangiography (DC) were done (ERCP 34 and PTC 8), less than 48 hs after MRCP. For the present study, the sensitivity was 100 per cent and specificity was 90 per cent of MRCP in the diagnosis of normal biliary tract. For the dilated biliary tract the sensitivity was 93 per cent and the specificity was 92 per cent . In bile duct obstruction the sensitivity was 88 per cent without false positive. MRCP diagnosed the presence of choledocholithiasis with a sensitivity of 74 per cent and specificity of 95 per cent, lower than reported in other studies. 73 per cent of our patients required some kind of therapeutic intervention. MRCP has high sensibility and specificity in the initial evaluation of patients with clinical obstructive jaundice and could replace the DC when is used for diagnostic purpose.

Congenital solitary biliary cyst of liver

This is a case report of a 5-year-old girl, who presented with abdominal pain and a mass in the epigastrium. The ultrasound revealed a cystic mass in the epigastrium anterior to left lobe of liver and stomach. On exploration a large cyst was found in the left lobe of liver containing bilious fluid. Roux-en-Y cystojejunostomy was performed, Recovery was uneventful. Case Reports: A 5-year-old girl presented with history of abdominal pain since two years, progressive weight loss for 1.5 years and a gradually increasing mass in the epigastrium for one year.The child developed fever and occasional vomiting over the last months. There was no history of jaundice, haematemesis,and respiratory problem. Clinical examination revealed a visible mass in the upper abdomen. It was about 10x10cms in size occupying epigastrium and adjacent left hypochondrium. Blood examination revealed haemoglobin 8.5 gm/dl and TLC 7100/mm3. Liver function tests were normal.Ultrasound scan revealed 9x7x6.8 cms echogenic cystic mass in the epigastrium anterior to the stomach with a lot of debris in it.According to one report it was not apparently related to the liver and pancreas.An upper barium series showed that the stomach was pushed to the left with a mass effect along the lesser curvature. Gastric emptying was normal. At laparotomy, a large thick walled cyst was found occupying almost whole of the left hepatic lobe. Right lobe of the liver and biliary passage were normal. Aspiration of the cyst revealed bilious fluid indicating communication with the biliary tree. Complete excision was impossible due to enormous size. A retrocolic Roux-en-Y cystojejunostomy was performed.A part of the cyst wall was sent for histopathology.The cytology of aspirated fluid revealed few blood cells,acute and chronic inflammatory cells, and necrotic material containing many gram-negative bacilli and few gram-positive cocci. Bile pigments, sugar and protein were present in the fluid. Histopathology revealed that cyst was lined by cuboidal epithelium and composed mainly of fibrovascular tissue, infiltrated with acute and chronic inflammatory cells. The patient recovered smoothly, and was discharged after 10 days. The patient was symptom free at 1-1/2 year follow up with no resident cyst in liver on ultrasound

La colangiografia endoscopica en afecciones de la via biliar en pacientes HIV+ / Endoscopic cholangiography in biliary tract diseases in HIV+ patients

El compromiso de la vía biliar en el curso de la infección por HIV se describió por primera vez en 1983. Desde entonces diversas infecciones oportunistas han sido responsables de lesiones biliares, definiendo una nueva entidad denominada colangiopatía asociada al HIV. Nuestro objetivo fue determinar la utilidad de la CPRE en el manejo de pacientes HIV + con colestasis. Desde agosto de 1994 a octubre de 1997 se efectuó CPRE en 11 HIV + (8 hombres, 3 mujeres, con edad promedio 35 años). La indicación de CPRE fue por ictericia (n=8); dolar en HD (n=8); fiebre (n=6); prurito (n=5) y aumento de la FA (n=10). Siete pacientes tenían Sida. En todos se realizó ecografía hepatobiliar. En 7 se tomó biopsia de la mucosa duodenal periampular. Las lesiones radiológicas se clasificaron según Cello en: 1- Estenosis papilar, con dilatación de la vía biliar extrahepática. 2- Colangitis esclerosantes (estenosis y dilataciones focales, intra y/o extrahepáticas). 3- Asociación de 1 y 2. 4- Estenosis larga del colédoco, en ausencia de cirurgía biliar o pancreatitis crónica. Cinco pacientes (45 por ciento) tuvieron anormalidades en la vía biliar. En 3 de ellos estuvieron relacionadas con la infección HIV: colangitis esclerosantes (n=2) y estenosis papilar (n=1). Dos presentaban litiasis coledociana. Cuatro de los 5 tuvieron dolor en HD y vía biliar dilatada en la ecografía. Se encontró Cryptosporidium en la biopsia duodenal de 1 paciente con colangitis esclerosante y en la estenosis papilar. Se colocó prótesis biliar sin esfinteropapilotomía en 2, con alivio del dolor y mejoría de la colestasis en uno de ellos. Los cálculos coledocianos se extrajeron endoscópicamente en uno y por cirugía en otro. Conclusión: La CPRE fue un método útil en el diagnóstico y tratamiento de las patologías biliares asociadas al HIV.

Hepatobiliary scintigraphy in the distinction between biliary hypoplasia and biliary atresia

The aim of this work is to see whether distinction between biliary atresia and biliary hypoplasia is possible or not and to present the value and usefulness of hepatobiliary scintigraphy in the investigation of infants with persistent hyperbilirubinemia. Seventy-seven patients of the age between five days and six months [average 62 days], 43 females and 34 males of which 65 Saudi, and 12 non-Saudis were investigated. Laboratory tests, abdominal ultrasound, hepatobiliary scintigraphy, liver biopsy explorative laparatomy and intraoperative cholangiography were performed whenever indicated. The findings on hepatobiliary scintigraphy of nonvisualization of the gallbladder and no activity in the bowel upto 24 hours post injection were considered consistent with the diagnosis of biliary atresia. Minimal bowel activity, or visualization of the gallbladder where consistent with biliary hypoplasia. In addition, the liver in the two entities appeared in a different shape and can be used as an additional distinctive feature. Thirty-four infants were diagnosed by hepatobiliary scintigraphy as having biliary atresia. Only 3 of the 34 were false positives as compared to cholangiogram and liver biopsy results. Five cases were biliary hypoplasia. Hepatobiliary scintigraphy in infants with persistent hyperbilirubinemia can be distinguished between BA and BH in a simple and noninvasive approach

Infecciones del tracto biliar: parte I: colangitis aguda / Infections of the biliary tract: part I: Acute colangitis

El término colangitis aguda se define como la inflamación del sistema ductal biliar, la cual puede se debido a procesos infecciosos, químicos, isquémicos o idiopáticos. Actualmente, aunque la mortalidad es importante, a pesar de la intervención quirúrgica, esta patología tiene un amplio espectro de severidad. En la presente revisión se tratan los aspectos relativos a la patogenia, microbiología, presentación clínica, diagnóstico y tratamiento de esta patología

Radiología intervencionista de la vía biliar, valor actual / Percutaneous treatments of biliary disease

El drenaje biliar percutáneo constituye una de las terapéuticas para la obstrucción biliar. Las causas neoplásicas de obstrucción biliar son: el cáncer de páncreas, vesícula y duodeno y la hipertrofia ganglionar por estas o por otras causas neoplásicas. Los métodos de drenaje son: la endoscopía, el percutáneo y la cirugía. La presentación clínica de esta patología es generalmente avanzada, lo que excluye a la cirugía en la mayoría de los casos. El método percutáneo transhepático de drenaje biliar, tiene un lugar preciso en esta patología, que mata al paciente por la colangitis antes que su neoplasia. Se trataron 57 pacientes con colocación de catéteres externos e internos, con experiencia en prótesis metálica, colecistostomía percutánea, combinaciones con la endoscopía y drenaje externo más gastrostomía. Se exponen y discuten sus resultados. Se utilizaron y evaluaron los últimos materiales disponibles. Además se drenaron 7 pacientes con bilomas de distintas etiologías, como único tratamiento, con excelente resultado. A pesar de su complejidad, estos procedimientos deben realizarse en todo centro hospitalario de imágenes, constituyéndose en una opción terapéutica importante

Absceso hepático piógeno: estudio retrospectivo; Hospital San Juan de Dios, 1989-1993 / Pyogenic liver abscess: a retrospective study; Hospital San Juan of Dios, 1989-1993

Se revisaron 18 casos de abscesos hepáticos piógenos diagnosticados y tratados en el Hospital San Juan de Dios entre 1989 y 1993. El 50 por ciento de loa pacientes presentaron un acausa probable de origen, destacando la patología biliar subyacente en el 33,3 por ciento . Los síntomas y signos más relevantes fueron el dolor abdominal (38,3 por ciento ), la fiebre (61 por ciento ) y la ictericia (44,4 por ciento ). El diagnóstico se confirmó a través de punción percutánea bajo visión ecográfica en el 50 por ciento ; examen de imagen seguido de cirugía en el 33,3 por ciento y hallazgo intraoperatorio en el 16,7 por ciento de los casos. El estudio microbiológico fue positivo en el 61,1 por ciento de los casos, destacando el alto rendimiento de la punción percutánea, con un 90,9 por ciento de positividad. Los gérmenes más frecuentemente aislados fueron: Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus y Bacteroides sp. En todos los casos se realizó tratamiento médico-quirúrgico con cirugía y antibióticos(40 por ciento ), drenaje percutáneo y antibióticos (36,4 por ciento ) y drenaje percutáneo y antibióticos seguidos de cirugía (22,7 por ciento ). Tres pacientes presentaron schok séptico con falla orgánica múltiple, de los cuales fallecieron dos (11,1 por ciento ). Se discuten los hallazgos microbiológicos y las alternativas terapéuticas disponiblñes en la actualidad