Hemobilia como causa infrecuente y grave de hemorragia digestiva alta / Hemobilia as a rare and serious cause of upper gastrointestinal bleeding

Introducción: La hemobilia es por definición una causa de hemorragia digestiva alta, donde existe una comunicación de la vía biliar en cualquiera de sus segmentos con vasos sanguíneos que desembocan a través de la ampolla de Vater. Su presentación es infrecuente y no sospechada en la práctica clínica diaria de gastroenterólogos, cirujanos, hepatólogos, clínicos e intensivistas, con un difícil manejo diagnóstico-terapéutico y una elevada morbi-mortalidad. Objetivo: Describir tres casos de pacientes con diagnóstico de hemobilia. Desarrollo: Se presentan tres casos con hemobilia que tuvieron una elevada mortalidad y con diferente etiología; en el primer caso por trombosis de la arteria hepática postrasplante hepático, el segundo secundario a un colangiocarcinoma de la unión hepatocística y el tercero con diagnóstico de un aneurisma de la arteria hepática derecha confirmado y parcialmente tratado por angiotomografía, posteriormente intervenido quirúrgicamente y único sobreviviente. Conclusiones: Resultaron tres casos con hemobilia de diferentes causas, con una elevada mortalidad por la intensidad de la hemorragia digestiva alta y las comorbilidades asociadas, además de señalar que ninguno de ellos presentó la tríada clásica reportada por Quincke(AU)

Introduction: Hemobilia is, by definition, a cause of upper gastrointestinal bleeding, where there is a communication of the bile duct in any of its segments with blood vessels that flow through the ampulla of Vater. It is rare and it is not suspected in the daily clinical practice of gastroenterologists, surgeons, hepatologists, clinicians and intensivists, hence the diagnostic-therapeutic management is difficult and it has high morbidity and mortality. Objective: To report three cases of patients with a diagnosis of hemobilia. Case report: We report three cases of hemobilia of high mortality and different etiology. The first case had post-liver transplantation hepatic artery thrombosis, the second had asecondary cholangiocarcinoma of the hepatocystic junction and the third had diagnosis of confirmed right hepatic artery aneurysm partially treated by CT angiography, subsequently operated on and the only survivor. Conclusions: These three hemobilia cases had different causes, and high mortality due to the intensity of the upper gastrointestinal bleeding and the associated comorbidities, in addition to noting that none of them exhibited the classic triad reported by Quincke(AU)

El rol de la endoscopia avanzada en enfermedades inflamatorias intestinales: terapéutica y vigilancia de neoplasias / The role of advanced endoscopy in inflammatory bowel diseases: therapeutic and neoplasms surveillance

Las enfermedades inflamatorias intestinales representan una patología de alta morbilidad. Esto debido a que se asocia a mayor su riesgo de desarrollo de neoplasias tanto colorrectales como colangiocarcinoma, desarrollo de complicaciones como fístulas, abscesos, estenosis intestinales espontáneas o postoperatorias y estenosis biliares en aquellas asociadas a colangitis esclerosante primaria. El rol del endoscopista avanzado en este grupo de pacientes se encuentra en la vigilancia de ambas neoplasias y en el tratamiento endoscópico de las complicaciones ya mencionadas. En relación a la vigilancia de cáncer colorrectal, existen distintas recomendaciones internacionales respecto a los intervalos y las técnicas de vigilancia, situándose la cromoendoscopia como método de elección emergente en los últimos años. Es importante destacar la publicación del uso de nueva nomenclatura para los hallazgos colonoscópicos durante la vigilancia del cáncer colorectal, abandonando los conceptos de DALM o lesiones o masas asociadas a displasia, lesiones tipo adenoma o no adenomatosas.

Inflammatory bowel diseases represent a high morbidity pathology given their high risk of developing both colorectal cancer and cholangiocarcinoma, besides the development of fistulas, abscesses, spontaneous or postoperative intestinal stenosis and biliary strictures in patients diagnosed with primary sclerosant cholangitis. The advanced endoscopist's rol in this group of patients lies within surveillance of both neoplasms and the endoscopic treatment of complications already mentioned. In relation to surveillance of colorectal cancer, there are various international recommendations regarding surveillance intervals and techniques, with chromoendoscopy emerging as a method of choice in recent years. It is important to highlight the use of new nomenclature for colonoscopic findings during surveillance, abandoning concepts as DALM, adenoma-like lesions or non adenoma-like lesions.

Descriptive Epidemiology of Cholangiocarcinoma and Clonorchiasis in Korea

In 2009, infection with the liver fluke Clonorchis sinensis (C. sinensis) was classified as "carcinogenic to humans" (Group 1) based on its involvement in the etiology of cholangiocarcinoma by the International Agency for Research on Cancer. However, little is known about the descriptive epidemiology of cholangiocarcinoma in Korea. We examined incidence trends of intrahepatic and extrahepatic cholangiocarcinomas, using data from the Korea National Cancer Incidence database for 1999-2005. The prevalence of C. sinensis infection was estimated from a recent population-based survey in rural endemic areas. Cholangiocarcinoma incidence rates are currently rising, even while primary liver cancer incidence rates are decreasing. Annual percent changes in cholangiocarcinoma incidence rates were 8% for males and 11% in females. Known areas of C. sinensis endemicity showed high incidence rates of cholangiocarcinoma. The positivity of C. sinensis eggs in stool samples from endemic areas was more than 25% of adults tested during 2005-2008. From a meta-analysis, the summary odds ratio for cholangiocarcinoma due to C. sinensis infection was 4.7 (95% confidence interval: 2.2-9.8). Approximately 10% of cholangiocarcinomas in Korea were caused by chronic C. sinensis infections. More specific policies, including health education and an extensive effort for early detection in endemic areas, are needed.

Seroprevalence of hepatitis virus B seropositive in the patients with cholangiocarcinoma: a summary.

The exact etiology of cholangiocarcinoma remains undetermined. One of the related risk factors for its development might be chronic viral hepatitis infection. Concerning hepatitis B infection, a correlation with cholangiocarcinoma has been documented. Here, we summarize knowledge on the prevalence of hepatitis B seropositivity among patients with cholangiocarcinomas. According to the literature review, five reports were recruited for further metanalysis, covering 565 cases. The overall prevalence of seropositive cancer was 14.5% (83/565). Further analysis revealed no correlation between prevalence rate and nationality of the studied population (P > 0.05). Therefore, hepatitis B infection might be a contributing factor for cholangiocarcinoma development.

Epidemiology of liver cancer: an overview.

The incidence of liver cancer varies widely throughout the world, with high rates in sub - Saharan Africa, eastern and southeastern Asia, and Melanesia and a low incidence in Northern and Western Europe and the Americas. Primary cancers of the liver in adults are of two main histological types: hepatocellular carcinoma, which is derived from hepatocytes, and cholangiocarcinoma, which is derived from the epithelial lining of the intrahepatic bile ducts. Hepatocellular cancer is a frequently occurring tumor in individuals in many developing countries, where several important risk factors have been demonstrated, including chronic infection with hepatitis B and C viruses and other environmental factors, such as exposure to aflatoxin, consumption of alcohol, and cigarette smoking. By contrast, cholangiocarcinoma is less common, accounting for only 7.7% of malignant tumors of the liver in the United States. However, in parts of Southeast Asia, cholangiocarcinoma occurs more frequently; it is responsible for more than 60% of liver tumors in northeastern Thailand. The geographic distribution worldwide coincides with endemic areas of the liver flukes, Opisthorchis viverrini and Clonorchis sinensis. The interaction between genes and the environment and the interplay of environmental factors, which include diet and other lifestyle parameters, illustrate the complexity underlying susceptibility.

Current status of infection-related gastrointestinal and hepatobiliary diseases in Thailand.

The objective of this overview is to assess the present situation with regards to gastrointestinal and hepatobiliary diseases prevailing in Thailand. In that context, special emphasis has been put on those forms of viral hepatitis prevalent in the region, namely, hepatitis A the frequency of which has undergone a change from hyper- to hypoendemic with a resulting decline in naturally acquired immunity; hepatitis B with its tendency to cause chronic liver disease mainly due to asymptomatic infections during early childhood and the impact of mass vaccination programs on its endemicity; hepatitis C which can also lead to chronicity; hepatitis D solely found as a coinfection with hepatitis B; hepatitis E acute cases of which can sporadically be found; hepatitis G encountered in healthy subjects at a prevalence similar to that seen in patients with chronic liver disease and rather more prevalent among people at risk for contracting blood borne agents; finally the novel hepatitis TT virus with a distribution comparable to that of hepatitis G virus and a similarly unclear role as to the etiology of serious liver disease. Particularly in connection with hepatitis B we have examined the situation regarding hepatocellular carcinoma which represents one of the most common malignancies among the Thai population. Cholangiocarcinoma caused by the liver fluke Opisthorchis viverrini is the most common form of liver cancer in the northeastern part of Thailand where an estimated 70% of the population are infested with the parasite. Peptic ulcer caused by Helicobacter pylori constitutes another common gastrointestinal affliction with the overall prevalence of antibodies to the agent amounting to 63 to 74% in patients exhibiting gastroduodenal symptoms. The final part of the paper deals with HIV-related gastrointestinal and liver disease and with amebic and pyogenic liver abscesses.

Cancer genes and cholangiocarcinoma.

Genes involved in cancer development include oncogenes and tumor suppressor genes. Ras oncogene and mutations in p53 tumor suppressor gene are commonly found in many types of cancer. In Thai patients with cholangiocarcinoma ras oncogenes occur less frequently than in other ethnic groups and furthermore, p53 mutations also occur with lower incidence when compared with Japanese subjects. It is unclear at this time the basis for these differences.