Guía de práctica clínica en atresia de las vías biliares / Clinical practice guidelines in biliary atresia

Basada en la mejor evidencia científica disponible, se presenta la guía de práctica clínica en atresia de vías biliares, la cual se define como una obstrucción progresiva de las vías biliares intra- o extrahepáticas en recién nacidos y lactantes pequeños y causa ictericia colestásica grave y cirrosis hepática. Es una enfermedad poco frecuente, de etiología desconocida, con mayor incidencia en países asiáticos. Clínicamente se expresa por ictericia obstructiva, acolia, coluria y hepatoesplenomegalia. Los complementarios expresan una hiperbilirrubinemia directa con aumento de las enzimas hepáticas, y el diagnóstico se confirma en nuestro hospital con la colangiografía, generalmente en el curso de una laparoscopía. El tratamiento es quirúrgico y consiste en la portoenterostomía de Kasai, con mejores resultados en cuanto al drenaje biliar si se realiza antes de los 60 días de vida, así como el trasplante hepático. La enfermedad tiene un curso progresivo hacia la cirrosis hepática en etapas tempranas de la vida, sobre todo si no se realiza el diagnóstico y tratamiento quirúrgico precozmente, con implicaciones en la supervivencia y calidad de vida de estos pacientes. Por tanto, referir precozmente al paciente con sospecha de atresia de vías biliares a un centro especializado es la piedra angular de la actitud médica. La presente guía de práctica clínica pretende ofrecer las herramientas técnicas estandarizadas para mejorar los resultados a los pacientes con esta enfermedad, así como contribuir con la docencia y las investigaciones(AU)

Based on the best scientific evidence available, it is presented the clinical practice guidelines on biliary atresia. This disease is defined as a progressive obstruction of the intra and/or extrahepatic bile ducts in newborns and young infants, causing severe cholestatic jaundice and cirrhosis of the liver. It is a rare disease of unknown etiology, with a higher incidence in Asian countries. It is clinically expressed by obstructive jaundice, acholia, choluria and hepatosplenomegaly. Laboratory tests show a direct hyperbilirubin and elevated liver enzymes, and in our hospital, the diagnosis is confirmed by a cholangiography, usually during a laparoscopy procedure. It has surgical treatment and it involves a Kasai portoenterostomy, with better results regarding biliary drainage if it is performed before 60 days of life, as well as liver transplant. This condition has a progressive course towards liver cirrhosis in early stages of life, mainly if the diagnosis and surgical treatment are not made timely, with implications for the survival and quality of life of these patients. Therefore, early referral of the patient with suspected biliary atresia to a specialized center is the cornerstone of the medical attitude. This clinical practice guidelines aims to offer standardized technical tools to improve the outcome for patients with this disease, as well as to contribute to teaching and research(AU)

Effect of silymarin on oxidative stress and liver histopathology in experimental obstructive jaundice model

ABSTRACT PURPOSE: To investigate the effect of silymarin on oxidative stress and hepatic injury induced by obstructive jaundice in an experimental model. METHODS: Thirty Wistar-Albino type female rats were divided into 3 groups each including 10 rats. Only laparotomy was performed in group 1. Bile duct ligation was performed in group 2. In group 3, bile duct ligation was performed and orogastic silymarin 300 mg/kg/day dose was given for seven days. At the end of seven days, rats were sacrificed. The blood and liver tissue samples were taken to be examined biochemically and histopathologically. RESULTS: The plasma and liver levels of malondialdehyde were significantly lower in silymarin group than in the bile duct ligated group. Although liver levels of GSH were significantly higher in silymarin group than in the bile duct ligated group, there was no significant difference between the plasma GSH levels of these groups. In silymarin group; the enlargement of hepatocytes, dilatation of canaliculi and the edema were regressed. CONCLUSION: Silymarin diminished the harmful effects of obstructive jaundice on liver.

Colédoco-duodenostomía guiada por ecoendoscopia en cáncer de páncreas avanzado con obstrucción duodenal / Endoscopic ultrasound-guided choledocho-duodenostomy in advanced pancreatic cancer with duodenal obstruction

La colangiopancreatografía retrógrada endoscópica (CPRE) se considera el tratamiento de primera línea para el drenaje biliar en pacientes con cáncer de páncreas. En los casos de fracaso por CPRE, generalmente se realiza un drenaje biliar transparietohepático o una derivación biliar quirúrgica. En la última década, las indicaciones y la utilidad de la ecoendoscopia en pacientes con cáncer de páncreas han ido creciendo, y se han informado numerosos casos de drenajes biliares guiados por ecoendoscopia como una alternativa al drenaje biliar percutáneo o quirúrgico en fracasos en la CPRE. Nuestro objetivo es comunicar un caso con cáncer de páncreas localmente avanzado que se presentó con ictericia indolora y síndrome coledociano con obstrucción biliar y duodenal, en el que se realizó una colédoco-duodenostomía guiada por ecoendoscopia mediante la colocación de una prótesis metálica autoexpandible.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the first-approach for biliary drainage. In cases of ERCP failure, patients are usually referred for percutaneous transhepatic biliary drainage or surgical biliary bypass. In the last decade, the indications of endoscopic ultrasound (EUS) in the management of patients with pancreatic cancer have increased, and numerous cases of EUS-guided biliary drainage have been reported in patients with failures during the ERCP. Our goal is to report a patient with locally advanced pancreatic cancer who presented with painless jaundice and cholestasis with biliary and duodenal obstruction. A EUS-guided choledochoduodenostomy was performed by placement of a self-expanding metal stent.

Ultrasonographic Diagnosis of Biliary Atresia Based on a Decision-Making Tree Model

OBJECTIVE: To assess the diagnostic value of various ultrasound (US) findings and to make a decision-tree model for US diagnosis of biliary atresia (BA). MATERIALS AND METHODS: From March 2008 to January 2014, the following US findings were retrospectively evaluated in 100 infants with cholestatic jaundice (BA, n = 46; non-BA, n = 54): length and morphology of the gallbladder, triangular cord thickness, hepatic artery and portal vein diameters, and visualization of the common bile duct. Logistic regression analyses were performed to determine the features that would be useful in predicting BA. Conditional inference tree analysis was used to generate a decision-making tree for classifying patients into the BA or non-BA groups. RESULTS: Multivariate logistic regression analysis showed that abnormal gallbladder morphology and greater triangular cord thickness were significant predictors of BA (p = 0.003 and 0.001; adjusted odds ratio: 345.6 and 65.6, respectively). In the decision-making tree using conditional inference tree analysis, gallbladder morphology and triangular cord thickness (optimal cutoff value of triangular cord thickness, 3.4 mm) were also selected as significant discriminators for differential diagnosis of BA, and gallbladder morphology was the first discriminator. The diagnostic performance of the decision-making tree was excellent, with sensitivity of 100% (46/46), specificity of 94.4% (51/54), and overall accuracy of 97% (97/100). CONCLUSION: Abnormal gallbladder morphology and greater triangular cord thickness (> 3.4 mm) were the most useful predictors of BA on US. We suggest that the gallbladder morphology should be evaluated first and that triangular cord thickness should be evaluated subsequently in cases with normal gallbladder morphology.

Primeras experiencias con drenaje biliar percutáneo de urgencia en la colangitis aguda / First experiences in performing urgent percutaneous biliary drainage for acute cholangitis

Introducción: la obstrucción biliar es motivo frecuente de morbilidad en los pacientes con metástasis hepáticas, adenopatías periportales y cáncer hepatobiliopancreático. La colangitis aguda es la complicación más temida, debido a su mortalidad. En este trabajo se presentan los primeros abordajes percutáneos realizados por cirujanos del Hospital Clínicoquirúrgico Hermanos Ameijeiras como herramienta para el tratamiento urgente de esta entidad. Objetivo: caracterizar el drenaje percutáneo transparietohepático de urgencia en pacientes con colangitis aguda e ictericia obstructiva. Métodos: se realizó un estudio descriptivo, prospectivo y aplicado con 30 pacientes atendidos de esta forma en dicha institución entre enero de 2008 y diciembre de 2010. Resultados: el diagnóstico etiológico preponderante fue el de tumor maligno de la cabeza del páncreas. La localización baja de la lesión duplicó a la localización alta. La mejoría clínica de la ictericia se evidenció en la mayoría de los pacientes después de una semana tras el procedimiento: el drenaje percutáneo constituyó el método definitivo en el 73,3 por ciento de los pacientes. Las edades medias para los distintos diagnósticos etiológicos exhibieron diferencias estadísticamente significativas. No hubo complicaciones ni mortalidad relacionadas con el procedimiento. Conclusiones: el drenaje biliar percutáneo guiado por ultrasonido es una herramienta útil y segura para el tratamiento de urgencia de la colangitis aguda. Es un método que pueden realizar los cirujanos generales con entrenamiento adecuado y específico, y tiene asociadas pocas complicaciones(AU)

Introduction: bile duct obstruction is a frequent source of morbidity among patients with liver metastasis, periportal lymph nodes and hepatobilopancreatic cancer. Acute cholangitis is the most feared complication because of its mortality. The present paper showed the first percutaneous approaches performed by surgeons in Hermanos Ameijeiras clinical and surgical hospital as a tool for treatment of this urgent complication. Objective: to characterize the urgent transparietohepatic bile drainage performed on patients with acute cholangitis and obstructive jaundice. Methods: this is a prospective, descriptive and applied study with 30 patients cared for in this institution from January 2008 through December 2010. Results: the most frequent etiology was malignancy of the pancreas head; the lower location of the lesion doubled the upper location. Most of the patients clinically improved their jaundice problems after one week of procedure. The percutaneous drainage was the definitive procedure in 73.3 percent of patients. Average ages for the various etiologic diagnoses showed statistically significant differences. There were no complications or death related with the procedure. Conclusions: US-guided percutaneous biliary drainage is a safe useful tool for the urgent treatment of acute cholangitis, it can be performed by general surgeons with specific adequate training and has few associated complications(AU)

Lemmel's Syndrome, an Unusual Cause of Abdominal Pain and Jaundice by Impacted Intradiverticular Enterolith: Case Report

Duodenal diverticula are detected in up to 27% of patients undergoing upper gastrointestinal tract evaluation with periampullary diverticula (PAD) being the most common type. Although PAD usually do not cause symptoms, it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present. This duodenal diverticulum obstructive jaundice syndrome is called Lemmel's syndrome. An 81-yr-old woman came to the emergency room with obstructive jaundice and cholangitis. Abdominal CT scan revealed stony opacity on distal CBD with CBD dilatation. ERCP was performed to remove the stone. However, the stone was not located in the CBD but rather inside the PAD. After removal of the enterolith within the PAD, all her symptoms resolved. Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay. Lemmel's syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present.

Effective Biliary Drainage and Proper Treatment Improve Outcomes of Hepatocellular Carcinoma with Obstructive Jaundice

BACKGROUND/AIMS: We investigated the treatment outcomes and prognostic factors of hepatocellular carcinoma (HCC) with obstructive jaundice. METHODS: Among 2,861 patients newly diagnosed with HCC between 2002 and 2011, a total of 63 patients who initially presented with obstructive jaundice were analyzed. Only four patients presented with resectable tumors and underwent curative resection. In the other patients who presented with unresectable tumors, 5, 8, 9, and 18 patients received transarterial chemoembolization (TACE), chemotherapy, radiotherapy, and combined treatment, respectively. Both the clinical and the treatment factors that affect overall survival (OS) were analyzed. RESULTS: The median OS was 4 months, and the 1-year OS rate was 23%. Patients who received treatment for HCC had a significantly improved OS rate compared with the patients who received supportive care only (1-year OS, 32% vs 0%; p<0.01). Responders to treatment showed a better OS than nonresponders (1-year OS, 52% vs 0%; p<0.01). TACE and radiotherapy resulted in relatively good treatment responses of 64% and 67%, respectively. In multivariate analyses, treatment of HCC (p=0.02) and the normalization of serum bilirubin by biliary drainage (p=0.02) were significantly favorable prognostic factors that affected the OS. CONCLUSIONS: Unresectable HCC with obstructive jaundice has a poor prognosis. However, effective biliary drainage and treatment of HCC such as with TACE or radiotherapy improves survival.

The Efficacy of Endoscopic Palliation of Obstructive Jaundice in Hepatocellular Carcinoma

PURPOSE: Obstructive jaundice in patients with hepatocellular carcinoma (HCC) is uncommon (0.5-13%). Unlike other causes of obstructive jaundice, the role of endoscopic intervention in obstructive jaundice complicated by HCC has not been clearly defined. The aim of this study was to evaluate the clinical characteristics of obstructive jaundice caused by HCC and predictive factors for successful endoscopic intervention. MATERIALS AND METHODS: From 1999 to 2009, 54 patients with HCC who underwent endoscopic intervention to relieve obstructive jaundice were included. We defined endoscopic intervention as a clinical success when the obstructive jaundice was relieved within 4 weeks. RESULTS: Clinical success was achieved in 23 patients (42.6%). Patients in the clinical success group showed better Child-Pugh liver function (C-P grade A or B/C; 17/6 vs. 8/20), lower total bilirubin levels (8.1+/-5.3 mg/dL vs. 23.1+/-10.4 mg/dL) prior to the treatment, and no history of alcohol consumption. The only factor predictive of clinical success by multivariate analysis was low total bilirubin level at the time of endoscopic intervention, regardless of history of alcohol consumption [odds ratio 1.223 (95% confidence interval, 1.071-1.396), p=0.003]. The cut-off value of pre-endoscopic treatment total bilirubin level was 12.8 mg/dL for predicting the clinical prognosis. Median survival after endoscopic intervention in the clinical success group was notably longer than that in the clinical failure group (5.6 months vs. 1.5 months, p< or =0.001). CONCLUSION: Before endoscopic intervention, liver function, especially total bilirubin level, should be checked to achieve the best clinical outcome. Endoscopic intervention can be helpful to relieve jaundice in well selected patients with HCC.

Rupture of Right Hepatic Duct into Hydatid Cyst

Echinococcal disease can develop anywhere in the human body. The liver represents its most frequent location. Hepatic hydatid cysts may rupture into the biliary tract, thorax, peritoneum, viscera, digestive tract or skin. We report a rare case with rupture of the right hepatic duct into a hydatid cyst in a woman with known hydatid disease and choledocholithiasis. The increased intra-luminal pressure in the biliary tree caused the rupture into the adjacent hydatid cyst. The creation of the fistula between the right hepatic duct and the hydatid cyst decompressed the biliary tree, decreased the bilirubin levels and offered a temporary resolution of the obstructive jaundice. Rupture of a hydatid cyst into the biliary tree usually leads to biliary colic, cholangitis and jaundice. However, in case of obstructive jaundice due to choledocholithiasis, it is possible that the cyst may rupture by other way around while offering the patient a temporary relief from his symptoms.

Comparison of Clinical Outcome and Cost-Effectiveness after Various Preoperative Biliary Drainage Methods in Periampullary Cancer with Obstructive Jaundice

The aim of this study was to compare the clinical outcome and cost-effectiveness of preoperative biliary drainage (BD) methods in periampullary cancer, and to suggest guidelines for selecting the appropriate preoperative BD method. Between October 2004 and August 2010, 211 patients underwent pancreatoduodenectomy after preoperative BD. Clinical outcome and cost-effectiveness of the preoperative BD methods were compared based on the final drainage method used and on intention-to-treat analysis. There was no significant difference in drainage duration between percutaneous transhepatic biliary drainage (PTBD) and endoscopic BD groups (14.2 vs 16.6 days, respectively; P = 0.121) but daily diminution of serum bilirubin level was higher in the PTBD group (0.7 vs 0.6 mg/dL/day, respectively; P = 0.041). Based on intention-to-treat analysis, drainage duration was shorter (13.2 vs 16.5 days, respectively; P = 0.049), daily diminution of serum bilirubin level was higher (0.7 vs 0.6 mg/dL/day, respectively; P = 0.041). Medical care cost was lower (14.2 vs 15.7 x 10(3) USD, respectively; P = 0.040) in the PTBD group than in the endoscopic BD group. When selecting the preoperative BD method, practitioners should consider that PTBD is more cost-effective and safer than endoscopic BD.

Comparison of Clinical Outcome and Cost-Effectiveness after Various Preoperative Biliary Drainage Methods in Periampullary Cancer with Obstructive Jaundice

The aim of this study was to compare the clinical outcome and cost-effectiveness of preoperative biliary drainage (BD) methods in periampullary cancer, and to suggest guidelines for selecting the appropriate preoperative BD method. Between October 2004 and August 2010, 211 patients underwent pancreatoduodenectomy after preoperative BD. Clinical outcome and cost-effectiveness of the preoperative BD methods were compared based on the final drainage method used and on intention-to-treat analysis. There was no significant difference in drainage duration between percutaneous transhepatic biliary drainage (PTBD) and endoscopic BD groups (14.2 vs 16.6 days, respectively; P = 0.121) but daily diminution of serum bilirubin level was higher in the PTBD group (0.7 vs 0.6 mg/dL/day, respectively; P = 0.041). Based on intention-to-treat analysis, drainage duration was shorter (13.2 vs 16.5 days, respectively; P = 0.049), daily diminution of serum bilirubin level was higher (0.7 vs 0.6 mg/dL/day, respectively; P = 0.041). Medical care cost was lower (14.2 vs 15.7 x 10(3) USD, respectively; P = 0.040) in the PTBD group than in the endoscopic BD group. When selecting the preoperative BD method, practitioners should consider that PTBD is more cost-effective and safer than endoscopic BD.

Pseudoaneurisma de la arteria hepática propia: reporte de un caso / Traumatic pseudoaneurysm of hepatic artery: case report

Los aneurismas de la arteria hepática son relativamente poco frecuentes y representan del 16 al 20 % de los aneurismas de las arterias viscerales. Las manifestaciones clínicas no son específicas y pueden incluir dolor abdominal, hemorragia digestiva alta o ictericia obstructiva, como el caso que se presenta. Caso clínico: presenta el caso de un hombre de 17 años remitido por ictericia obstructiva; se determinó que la patología causante era un pseudoaneurisma de más de 30 mm. de diámetro en la arteria hepática propia, de origen traumático. La evolución fue tórpida por las lesiones asociadas, pese a la colaboración intensiva de distintas especialidades y al tratamiento electivo. Conclusiones: este tipo de aneurisma ocurre con muy poca frecuencia y tiene un pronóstico muy incierto. El tratamiento debe ser necesariamente individual para cada caso. La ictericia constituyó el signo de debut e indicó la gravedad del pseudoaneurisma de la arteria hepática, cuyo pronóstico es incierto, precisando tratamiento individualizado. Debe seleccionarse cuidadosamente el abordaje que requiere cada paciente, y aunque la vía endovascular es una opción, a veces es imposible recurrir a ella por la complejidad de la localización de la lesión, de ahí la necesidad de que el cirujano posea experiencia en el eje hepatobiliar y su vascularización.

Hemobilia: diagnóstico por imágenes a propósito de dos casos / Hemobilia: imaging report of two cases

El diagnóstico de hemobilia resulta difícil en la práctica diaria; el tratamiento está destinado a detener el sangrado y resolver la causa del mismo. Los aneurismas de la arteria hepática constituyen una patología poco frecuente y una de las causas raras de hemobilia, la presentación clínica es inespecífica e incluye dolor abdominal, ictericia obstructiva y sangrado digestivo alto. Recientemente con el desarrollo de la radiología intervencionista se ha logrado reducir el número de cirugías, mediante la embolización transarterial, obteniendo tasas de éxito entre 80-100%.2 Se presentaran 2 casos de hemobilia, todos fueron estudiados con ecografía, colangiografía por resonancia magnética y angiotomografía. Se describen las características de esta patología con los distintos métodos por imágenes; se destaca la indicación de la arteriografía no sólo para el diagnóstico sino también como tratamiento (embolización). En un caso, la hemobilia fue identificada por duodenoscopia y en el otro por gastroscopia. A ambos pacientes se le realizó ultrasonido abdominal el cual mostró hepatomegalia, vesícula distendida con barro biliar, dilatación de vías biliares e imagen hipoecogénica en segmento V hepático. El doppler revela flujo activo en la vía biliar. Angiotomografía y colangiografía por resonancia magnetica revelaron aneurisma en la arteria hepática derecha en íntimo contacto con la vía biliar, correlacionado con la imágen hipoecogénica observada por ultrasonido. Ambos casos fueron resueltos por la liberación de coils intra-arteriales sin complicaciones.

The diagnosis of hemobilia is difficult in daily practice; treatment is designed to stop the bleeding and resolve its cause. Hepatic artery aneurysms are an uncommon condition and one of the rare causes of hemobilia; clinical presentation is nonspecific and includes abdominal pain, obstructive jaundice and upper gastrointestinal bleeding. Recently, due to the development of interventional radiology, the number of surgeries has successfully been reduced through transarterial embolization, achieving success rates between 80-100%.2 We present 2 cases of hemobilia that were evaluated by ultrasound, MRI cholangiography and angiotomography. We describe the characteristics of this disease with the use of different imaging methods; with emphasis on the use of arteriography not only for diagnosis but also for treatment (embolization). In one case, the hemobilia was identified by duodenoscopy, and in the other by gastroscopy. Both patients underwent abdominal ultrasound that showed hepatomegaly, distended gallbladder with biliary sludge, distended bile ducts and a hypoechoic image in liver segment V. Doppler revealed active flow into the bile duct. Angiotomography and MRI reported an aneurysm in the right hepatic artery in close contact to the bile duct, correlated to the hypoechoic image seen by ultrasound. Both cases were treated with transarterial coil placements without any complications.

Multiple risks and early language development.

Objective. To examine the relationship between cumulative biological and environmental risk factors and the language development of children less than 3 years. Methods. A sample of 253 children aged 2 to 35 months, from an urban centre in north India were evaluated for language development. The main outcome measure was the language quotient (LQ) of the child as evaluated by the Clinical Linguistic Auditory Milestone Scale (CLAMS). Twelve possible risk factors, 4 biological and 8 environmental, were selected. Biological risk factors included preterm birth, low birth weight, history of birth asphyxia, and history of neonatal jaundice. The environmental risk factors included low income, large family size, minimal father’s and mother’s education, disadvantaged caste, low level of occupation of head of the household, absence of father, and higher birth order. A multiple risk score was created and categorized into 3 groups: low risk (0 to1), moderate risk (2 to 3) and high risk (4 and above). Results. There was a significant (F=4.80, p<.000) general downward linear trend in the LQ of the child as the number of risk factors increased. The difference in the LQ of the children with no risk factor and those with 8 risk factors was 21.21 LQ points and each risk factor reduced the LQ of the children by 2.63 points. Conclusion. Children experience many risk factors but the most detrimental effects on language development are caused when multiple biological and environmental risk factors act on a single child.

Icterícia colestática por lesões de natureza maligna: ensaio iconográfico / Cholestatic jaundice by malignant lesions: pictorial essay

A icterícia colestática de natureza tumoral maligna tem como causas mais frequentes o tumor da cabeça do pâncreas, o tumor da papila, o colangiocarcinoma e os quadros obstrutivos biliares determinadospor lesão secundária hepática parenquimatosa ou linfonodal. Os pacientes geralmente se apresentam com perda ponderal, dor abdominal, icterícia progressiva e aumento de bilirrubina direta, sendo fundamental a avaliação pelos métodos de imagem para o adequado diagnóstico, estadiamento e planejamento terapêutico. O presente ensaio ilustra, com correlação anatomocirúrgica, os aspectos de imagem da ultrassonografia, tomografia computadorizada e, em situaçõesespecíficas, colangiorressonância, das principais neoplasias malignas que cursam com icterícia colestática.

Malignant obstructive jaundice is most commonly caused by cancerof pancreatic head, papilla tumor, cholangiocarcinoma and biliary obstruction induced by secondary lesions of the liver or lymph nodes. Patients usually present with weight loss, abdominal pain, jaundice and progressive increase of direct bilirubin, being essential the evaluation by imaging methods for the proper diagnosis, staging and therapeutic planning. This essay illustrates the imaging aspects of ultrasound and computed tomography – and in specific situations magnetic resonance cholangiography – of the major malignancies that lead to cholestatic jaundice.

Primary Biliary Lymphoma Mimicking Cholangiocarcinoma: A Characteristic Feature of Discrepant CT and Direct Cholangiography Findings

Primary non-Hodgkin's lymphoma arising from the bile duct is extremely rare and the reported imaging features do not differ from those of cholangiocarcinoma of the bile duct. We report a case of a patient with extranodal marginal zone B-cell lymphoma of mucosa associated lymphoid tissue (MALT), who presented with obstructive jaundice and describe the distinctive radiologic features that may suggest the correct preoperative diagnosis of primary lymphoma of the bile duct. Primary MALT lymphoma of the extrahepatic bile duct should be considered in the differential diagnosis when there is a mismatch in imaging findings on computed tomography or magnetic resonance imaging and cholangiography.

Evaluation of the mitochondrial respiration of cardiac myocytes in rats submitted to mechanical bile duct obstruction / Avaliação da respiração mitocondrial de miócitos cardíacos em ratos ictéricos sumetidos à obstrução do ducto biliar

PURPOSE: The objective of the present study was to evaluate the capacity of the myocardium for energy production by the analysis of mitochondrial respiration in rats with jaundice submitted to bile duct ligature. METHODS: Sixteen male Wistar rats were divided into 2 Groups: Group SO submitted to nontherapeutic laparotomy (sham operation) and Group IC (icteric group) submitted to bile duct ligature. After 7 days, laparotomy was again performed in all animals for cardiac muscle extraction and analysis. Mitochondrial oxygen consumption was determined by stage 3 velocity and stage 4 velocity. The respiratory control ratio (RCR) was obtained by the ratio of stage 3 to stage 4 velocity. Statistical analysis was performed by the Mann-Whitney test, with the level of significance set at 5 percent (p<0.05). RESULTS: Statistical analysis revealed a significant drop in oxygen consumption during stage 3 mitochondrial respiration in group IC compared with SO, whereas the values obtained during stage 4 were basically identical for the two groups. Likewise, RCR values exhibited a significant reduction. CONCLUSION: The cellular respiration of the "jaundiced heart" is depressed. This was demonstrated by the reduced capacity of cardiac mitochondria to consume oxygen and synthesize ATP, supporting the idea of a latent cardiac impairment responsible for the hemodynamic decompensation occurring during cholestasis.

OBJETIVO: A proposta deste trabalho é avaliar a capacidade de produção energética do miocárdio mediante análise da respiração mitocondrial em ratos ictéricos submetidos à ligadura do ducto biliar. MÉTODOS: Foram utilizados 16 ratos Wistar machos divididos em 2 Grupos: Grupo SO , os quais foram submetidos à Laparotomia branca e Grupo IC, os quais sofreram ligadura do ducto biliar para o desenvolvimento de icterícia obstrutiva. Todos os animais após 7 dias de cirurgia foram submetidos à nova laparotomia para extração e análise do músculo cardíaco. O consumo de oxigênio pelas mitocôndrias foi determinado pela velocidade do estado 3 e velocidade do estado 4. A razão do controle respiratório (RCR) foi obtida pela relação entre as velocidades dos estados 3 e 4. A análise estatística foi feita pelo teste de Mann-Whitney com nível de significância de 5 por cento (p<0.05). RESULTADOS: Observou-se queda estatisticamente significante nos valores do consumo de oxigênio do estado 3 da respiração mitocondrial no grupo IC em relação ao SO, no entanto os valores para estado 4 permaneceram basicamente inalterados entre os grupos. Os valores de RCR entre os grupos também apresentaram diminuição significativa. CONCLUSÃO: A respiração celular do 'coração ictérico' está deprimida em decorrência da redução da capacidade da mitocôndria cardíaca em consumir oxigênio e sintetizar ATP, o que pode contribuir para a disfunção cardiovascular na vigência da colestase.

effects of combined use of glutamine and growth hormone on the bacterial translocation associated with obstructive jaundice

To investigate the effects of combined use of glutamine and growth hormone on bacterial translocation. The study was performed at the laboratories of the Department of Physiology at Ataturk University Medical School, Erzurum, Turkey between June and September 2007. Forty rats divided into 5 groups of 8, were included in the study. In the study groups, the common bile duct was ligated to obtain obstructive jaundice. The rats in the control group CG were given sodium chloride, in the glutamine group GLG they were given glutamine, in the growth hormone group GHG, growth hormone, and in the glutamine + growth hormone group GLGHG glutamine + growth hormone at equal doses by the same methods. Blood, spleen, liver, lymph node, and cecal content samples were obtained. Total bilirubin TB, alkaline phosphates ALP, and gamma glutamine transferase GGT activities were evaluated. In the CG, cecal contents were higher than in the GLG, and cecal contents and BT were higher than in the GHG and the GLGHG. The BT rate was the lowest in the GLGHG, with a borderline difference with the values of the GLG and GHG. We found that in preventing BT, combined use of glutamine, and growth hormone was more effective than using each of these agents alone

Hepatocolangitis por drogas simulando un hepatocarcinoma / Drug-induced hepatocholangitis with characteristics of hepatocarcinoma

La hepatotoxicidad por drogas es una entidad frecuente, con un amplio espectro de manifestaciones y muchas veces subestimada por los médicos. Existen escasos reportes acerca de los hallazgos anatomopatológicos en pacientes con toxicidad hepática aguda causada por drogas...El hallazgo de atipias celulares que simulan neoplasias en tejidos agredidos por drogas es una situación en la cual la experiencia del patólogo y una historia clínica completa son decisivos para orientar el diagnóstico.

Obstructive jaundice induces early depression of mitochondrial respiration in rat hepatocytes

INTRODUCTION: Oxidative phosphorylation dysfunction of hepatocyte mitochondria is involved in the pathophysiology of organ dysfunction following obstructive jaundice (OJ). However the time period from biliary occlusion to the occurrence of the dysfunction has not been determined decisively. PURPOSE: To evaluate the early effects (1 d and 7 d) of OJ on liver mitochondria respiratory function in rats. METHODS: Male Wistar rats (200-250 g) were randomly divided into the following 3 groups: laparotomy plus OJ for 24 h (1d group) (n = 10); laparotomy plus OJ for 7 d (7d group) (n = 10); sham control procedure (CTR group) (n = 12). At the end of OJ periods, total serum bilirubin level, hepatic enzyme activity levels (GOT, GTP, Gama-GT, ALP), mitochondrial respiration phases S3 and S4, as well as the respiratory control ratio (RC = S3/S4), and ADP consumption/oxygen consumption (ADP/O) ratio, were determined. RESULTS: Total serum bilirubin, activity of most hepatic enzymes, and O2 consumption during basal (S4) respiration were increased in the 1d and 7d groups (ANOVA, p = 0.05 vs. CTR). After ADP addition, the O2 consumption rate (S3) in the 1d group remained similar to the CTR rate (ANOVA p > .05), while the RC rate was reduced (ANOVA, p = 0.001) vs. CTR. The effects observed on mitochondrial respiration in the 1d group were exacerbated in the 7d group. CONCLUSION: These results indicate that OJ induces early (24 h) depression of liver mitochondria respiration, and thus may lead to early reduction in the production of high energy bonds.

INTRODUÇÃO: A disfunção da fosforilação oxidativa das mitocôndrias do hepatócito está envolvida na fisiopatologia da disfunção orgânica subseqüente à icterícia obstrutiva (IO). Entretanto, a precocidade da ocorrência desta disfunção permanece obscura. OBJETIVO: Avaliar o efeito precoce da IO na função respiratória mitocondrial em ratos. MÉTODOS: Ratos Wistar machos (200 a 250g) foram randomizados em 3 grupos que foram submetidos a laparotomia mais: IO por 24hs (grupo 1d)(n=10); IO por 7 dias (grupo 7d)(n=10; procedimento simulado (grupo CTR)(n=12). Ao final dos períodos de IO, foram determinados: bilirrubina sérica total, atividade de enzimas hepáticas (TGO, TGP, Gama-GT, FA), e as fases S3 e S4 da respiração mitocondrial, bem como o razão do controle respiratório (RC = S3/S4), e a razão entre consumo de ADP/consumo de oxigênio (ADP/O). RESULTADOS: Observou-se significativo aumento de bilirrubina sérica total, enzimas hepáticas, e consumo de O2 durante a respiração basal (S4) no grupo de IO por 24hs (ANOVA, p=0.009). Após adição de ADP, a taxa de consumo de O2 (S3) não diminuiu significativamente no grupo de IO, comparado com o CTR (ANOVA, p>0.05); entretanto, a razão do controle respiratório (RC) foi significativamente mais baixa comparada com o CTR (ANOVA, p=0.001). Os efeitos observados na respiração mitocondrial no grupo do dia 1d estavam exacerbados no grupo 7d. CONCLUSÃO: Estes resultados indicam que a icterícia obstrutiva induz depressão precoce (24hs) da respiração mitocondrial, e pode assim levar à redução da produção de ligações de alta energia.