Rendezvous radiológico-endoscópico para manejo de obstrucción biliar: Reporte de casos y revisión de la literatura / Endoscopic-radiologic rendezvous for biliary obstruction management: Case report and literature review

La obstrucción biliar de diverso origen constituye un problema clínico frecuente, con importante impacto sobre la calidad de vida de los pacientes y que plantea el riesgo permanente de colangitis. El manejo de estos pacientes ha evolucionado en el tiempo, haciendo acopio de diversos desarrollos tecnológicos e involucrando a clínicos, cirujanos, gastroenterólogos y radiólogos intervencionistas. Reportamos aquí cuatro casos de pacientes con obstrucción biliar que, a pesar de las importantes diferencias demográficas y etiológicas, pudieron ser exitosamente manejados, abordando la vía biliar con la técnica de Rendezvous radiológico endoscópico.

Biliary obstruction of different origin is a common clinical problem, with significant impact on the patients´ quality of life and poses a permanent risk of cholangitis. The management of these patients has evolved over time, makes collection of various technological developments and involve clinicians, surgeons, gastroenterologists, and interventional radiologists. Were port four cases of biliary obstruction that despite the significant demographic and clinical differences between them could be successfully managed approach in the biliary tract with the technique of radiological endoscopic Rendezvous.

Colangiografia transcolecística percutânea em cães / Percutaneous transcholecystic cholangiography in dogs

Enfermidades que acometem o sistema biliar dos cães, principalmente as relacionadas a processos obstrutivos, não são raras, sendo em sua maioria, de etiologia grave, necessitando de tratamento cirúrgico. Os métodos de diagnóstico por imagem para investigação de obstruções biliares atualmente realizados na medicina veterinária como a ultrassonografia, radiografia convencional e tomografia computadorizada, apresentam algumas restrições, como sensibilidade insuficiente, e em muitas regiões inviabilidade de realização. Desta forma, vários pacientes são submetidos a procedimentos cirúrgicos antes da obtenção do diagnóstico preciso, que caracterize e identifique o local de obstrução. Neste contexto, o presente trabalho objetivou padronizar e descrever a técnica de colangiografia transcolecística percutânea em cães, consistindo na injeção percutânea de contraste no interior da vesícula biliar por meio de punção ecoguiada, permitindo a visualização e avaliação semiológica das vias biliares intra e extra-hepáticas, mediante projeções radiográficas. A técnica foi executada 10 vezes em seis cães clinicamente saudáveis, sendo a punção da vesícula biliar realizada através do nono espaço intercostal direito próximo ao esterno com auxílio de um cateter 20G, injetando a dose de 1ml de contraste para cada 4kg de peso vivo. Após a injeção do contraste foram efetuadas radiografias seriadas da região abdominal, em projeção lateral esquerda e ventrodorsal, as primeiras projeções foram realizadas imediatamente após a injeção do contraste sendo repetidas após cinco e dez minutos. Nenhum dos animais apresentou quaisquer efeitos colaterais decorrentes da técnica, sendo verificados por meio de observação dos mesmos e provas de função hepática comparativas pré e pós procedimento. A técnica demonstrou eficácia na demonstração radiográfica da árvore biliar, possibilitando a avaliação semiológica das vias biliares intra e extra-hepáticas. Tal avaliação permite identificar, caracterizar e localizar possíveis processos obstrutivos que acometem as vias biliares na espécie canina.(AU)

Obstructive biliary pathway diseases are not rare in dogs, especially those with severe clinical signs and those that need surgical treatment. Image diagnostic exams to evaluate biliary tract, like ultrasound, conventional X-ray and CT, have been used in veterinary medicine with some restrictions such as low sensibility, and in many regions unfeasibility of achievement. Due to this, most of the pacients with biliary obstruction sings are submitted to surgical procedure before an accurate diagnostic of the disease. This paper aimed to standardize and describe the percutaneous transcolecystic cholangiography in dogs that consists in the injection of contrast inside of the gall bladder guided by ultrasound. It allows to see all the bililary tract, using X-ray. The technique was performed 10 times in six clinical healthy dogs. The puncture was performed in the 9th intercostal right space near to the sternum using a 20G catheter, the dose was 1ml per 4kg. After contrast injection, serial radiographs of the abdominal region were made, in left lateral projection and ventrodorsal, the first projections were performed immediately after contrast injection and repeated after five and ten minutes. No animal showed any side effect due to the technique, this was confirmed by observation and by hepatic function evaluation. The technique was considered efficacious to visualize all the biliary tree and to see any possible obstruction in ill dogs.(AU)

Diagnosis of biliary atresia in Syrian population

This study aims to define the role of the liver biopsy and scintigraphy in the diagnosis of the bilairy atresia [BA] in a developing country, as the first published study in our country [Syria]. Twenty two patients with cholestatsis, during 2008-2009, were studied for clinical presentations, total bilirubin, SGPT, PT, liver biopsy [LB], scintigraphy [SNT], and cholangiography in positive cases. The false positive and negative cases of SNT were analyzed. Nine patients completed the study, 5 males, and 4 females. Age range between 21 and 120 days, mean age 73.1 days. SNT and LB was incompatible with BA in all 9 cases. Cholangiography proved extrahepatic biliary atresia in 7 cases [77%] and was normal in 2 cases [23%], thus LB and SNT gave false results in these cases. Our study proves again that the diagnosis of biliary atresia can't be made by only one tool, the cholangiogram still the best and final test to make it

Applications of Multidetector-row CT for the Imaging Diagnosis of Liver Disease / 대한소화기학회지

Owing to the development of multidetector-row CT (MDCT), capability in the imaging diagnosis of liver disease has increased surprisingly. First, a marked decrease in scan duration of the liver enables us to select the accurate scan time optionally. Secondly, a marked decrease in slice thickness enables us to render isotropic and three-dimensional images completely. In this pictorial review, we described the optimal contrast enhancement of the liver on MDCT and its significance as well as the applications of isotropic and three-dimensional images obtained by MDCT.

Radiological evaluation of obstructive jaundice

A study involving 125 patients of obstructive jaundice was conducted in Combined Military Hospital and Military Hospital Rawalpindi. The study group predominantly consisted of female patients between 40 and 60 years. Ultrasonography and endoscopic retrograde cholangiopancreatography [ERCP] were the commonest radiological investigations used. Ultrasonography [USG] was performed in 100% patients. It successfully differentiated obstructive from non-obstructive jaundice. ERCP was perfomed in 100 patients [80%]- It was helpful in permitting direct, non-surgical imaging of pancreatic and bilary ducts. It proved to be useful diagnostic tool as it provided gastroduodenoscopy, cholangiography and pancreatography with a single examination. Percutaneous transhepatic cholangiography [PTC] was helpful in assessing the presence, site and cause of obstruction

Diagnostic accuracy of ultrasonography and percutaneous transhepatic cholangiography in pereoperative evaluation of obstructive jaundice

A study was conducted in Radiology Department, Combined Military Hospital, Rawalpindi to determine the combined efficacy of Ultrasonography [USG] and Percutaneous Transhepatic Cholangiography [PTC] in the preoperative evaluation of obstructive jaundice. After initial screening by means of Ultrasonography, 22 patients were selected for PTC. Of them 14 underwent surgery, providing an opportunity for assessing the separate and combined accuracy of both the modalities. Both were equally accurate detecting stones in the common bile duct [100%]. In assessing stones of the gallbladder, USG [100%] was found to be superior to PTC [0%]. Similarly, USG [87.5%], outperformed PTC [37.5%] in identifying enlargements of the gallbladder. PTC [87.5%] however, surpassed USG [28.5%] in detecting extrinsic compression of the common bile duct [CBD] by nepotistic pancreatic enlargements. Combination of these two modalities resulted in a much improved diagnostic yield and proved to be an economical and safe yet formidable means of preoperative assessment of obstructive jaundice without the need for the more expensive CT scan, or the less available endoscopic retrograde cholangiopancreatography [ERCP]

Validity of choldochoscope in the diagnosis and possible management of surgical obstuctive jaundice

A consecutive series of 50 common bile duct exploration was studied to asses the value of intraoperative flexible choledochoscope in the diagnosis and management of surgical obstructive jaundice and to evaluate the efficiency of the choledochoscopy in clearing the common bile duct from stones after choledocholithotomy by the use of postoperative T-tube cholangiogram. Each patient had a thorough history and physical examination as well as the necessary laboratory studies and abdominal ultrasound was done for all patients. Distribution of age incidences of patients was three under the age of 40, 25 between 40-60 and 22 over 60. The causes of obstructive jaundice were calcular obstructive jaundice [33 patients], cancer head of pancreas [ten patients], postoperative stricture [four patients], cholangiocarcinoma [two patients] and one case of a choledochal cyst. It was concluded that intraoperative choledochoscopy is necessary, since it reduces the incidence of retained stones and enables the assessment of the pathological lesions within the biliary tract and aids in operative decision-making

cytological features of stagnant bile in patients with obstructive biliary disorders

Nineteen bile samples were aspirated during endoscopic cholangiography [ERCP] for patients with obstructive jaundice. The patients were assessed clinically, by laboratory investigations, abdominal ultrasonography, ERCP, operative biopsy and by cytology to determine the cause for the obstruction and to evaluate the diagnostic celluiar features of bile cytology obtained during ERCP. The results of 19 cases consisted of 10 malignant cases, 5 benign and 4 atypical smears. The cytological features differentiating benign from malignant lesions gave quite encouraging results with respect to the reliability of diagnosis of bile samples particularly in association with ERCP, sensitivity 76.9%, specificity 87.5% and diagnostic accuracy 82.6%. Such a method can therefore be considered as a simple reliable, rapid method for preoperative evaluation of obstructive jaundice patients and for the early detection of malignancy in screening programs

The value of percutaneous transhepatic cholangiography in the diagnosis of obstructive jaundice.

Percutaneous transhepatic cholangiography (PTC) using Chiba needle was employed to diagnose obstructive jaundice in 31 subjects. It was successful in all 27 (87%) subjects who had dilatation of the biliary tree. Out of them, 15 had features suggestive of carcinoma, 9 had features of stone and 3 had features of stricture of the common bile duct (CBD). Surgery was done in 11 cases and PTC diagnosis of carcinoma of CBD in 4 and stricture of the same in one subject were confirmed. While in the remaining 6 subjects with a PTC diagnosis of CBD stone, 4 were found to be so and 2 had stricture of the duct. Three subjects had complications such as bile peritonitis, cholangitis and shock. In majority of the cases, the biochemical parameters were inconclusive. These results suggest that PTC may be useful in the diagnosis of obstructive jaundice and this procedure should be employed more widely.