Biopsia endobiliar con pinza por acceso percutáneo: primera experiencia en Uruguay / Biopsy of biliary ducts via percutaneous catheterization: first experience in Uruguay / Biópsia endobiliária com pinça de acesso percutâneo: primeira experiência no Uruguai

Resumen: Presentamos la primera experiencia en Uruguay de una biopsia endobiliar con pinza por acceso percutáneo que realizáramos en una paciente con estenosis biliar hiliar de probable causa neoplásica. Hasta nuestro conocimiento, no existen reportes de esta técnica en Uruguay. La difusión de la disponibilidad de esta técnica en nuestro medio es de gran importancia, ya que permite al equipo médico tratante disponer de una nueva herramienta para el manejo diagnóstico de las estenosis biliares.

Abstract: The study presents the first experience in Uruguay of a forceps biopsy of biliary ducts via percutaneous catheterization performed in a patient with hilar biliary strictures probably caused by a tumor. As far as we know, no reports on this technique have been published in our country. It is important to spread the availability of this technique in our country since it provides the medical team with a new tool for the diagnostic handling of biliary strictures.

Resumo: Apresentamos a primeira experiência no Uruguai de uma biópsia endobiliária com pinça de acesso percutânea realizada em um paciente com estenose biliar hilar de provável causa neoplásica. Para nosso conhecimento, não há relatos dessa técnica no Uruguai. A difusão da disponibilidade dessa técnica em nosso ambiente é de grande importância, pois permite à equipe médica responsável o tratamento ter uma nova ferramenta para o manejo diagnóstico da estenose biliar.

Quiste de conducto cístico / Cystic duct cyst

Los quistes congénitos de la vía biliar son infrecuentes y se definen por la dilatación quística del árbol biliar en cualquiera de sus porciones. Los quistes del conducto cístico son aún menos frecuentes. Su etiología permanece incierta y el tratamiento consiste en la resección debido a su potencial desarrollo de malignidad. Presentamos el caso de una paciente en la que se diagnosticó dilatación del conducto cístico y fue tratada por vía laparoscópica.

Congenital biliary duct cysts are rare and are defined as cystic dilatations of the biliary tree in any of its portions. Cystic duct cysts are more uncommon. Their etiology remains uncertain and they should be resected due to the possible development of malignancy. We report the case of a female patient with a diagnosis of dilation of the cystic duct that was treated with laparoscopic surgery.

T2-Weighted Liver MRI Using the MultiVane Technique at 3T: Comparison with Conventional T2-Weighted MRI

OBJECTIVE: To assess the value of applying MultiVane to liver T2-weighted imaging (T2WI) compared with conventional T2WIs with emphasis on detection of focal liver lesions. MATERIALS AND METHODS: Seventy-eight patients (43 men and 35 women) with 86 hepatic lesions and 20 pancreatico-biliary diseases underwent MRI including T2WIs acquired using breath-hold (BH), respiratory-triggered (RT), and MultiVane technique at 3T. Two reviewers evaluated each T2WI with respect to artefacts, organ sharpness, and conspicuity of intrahepatic vessels, hilar duct, and main lesion using five-point scales, and made pairwise comparisons between T2WI sequences for these categories. Diagnostic accuracy (Az) and sensitivity for hepatic lesion detection were evaluated using alternative free-response receiver operating characteristic analysis. RESULTS: MultiVane T2WI was significantly better than BH-T2WI or RT-T2WI for organ sharpness and conspicuity of intrahepatic vessels and main lesion in both separate reviews and pairwise comparisons (p < 0.001). With regard to motion artefacts, MultiVane T2WI or BH-T2WI was better than RT-T2WI (p < 0.001). Conspicuity of hilar duct was better with BH-T2WI than with MultiVane T2WI (p = 0.030) or RT-T2WI (p < 0.001). For detection of 86 hepatic lesions, sensitivity (mean, 97.7%) of MultiVane T2WI was significantly higher than that of BH-T2WI (mean, 89.5%) (p = 0.008) or RT-T2WI (mean, 84.9%) (p = 0.001). CONCLUSION: Applying the MultiVane technique to T2WI of the liver is a promising approach to improving image quality that results in increased detection of focal liver lesions compared with conventional T2WI.

The Expanding Role of Contrast-Enhanced Endoscopic Ultrasound in Pancreatobiliary Disease

Since its introduction into clinical practice in the 1980s, endoscopic ultrasound (EUS) has been described as a good imaging modality for the diagnosis of pancreatobiliary diseases. However, differential diagnosis of certain lesions based only on B-mode ultrasound images can be challenging. Clinical use of ultrasound contrast agents has expanded the utility of EUS from that of detection to characterization of pancreatobiliary lesions based on the enhancement features of contrast-enhanced EUS (CE-EUS). Current low mechanical index techniques for CE-EUS using second-generation contrast agents have a number of distinct advantages over conventional diagnostic modalities in evaluating pancreatobiliary lesions, including real-time assessment of perfusion pattern, availability, and the absence of exposure to radiation. This article describes the technical aspects of CE-EUS and reviews the expanding indications in pancreatobiliary diseases and further development of this technique.

Safety and Utility of Single-Session Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography for the Evaluation of Pancreatobiliary Diseases

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are essential for diagnosing and treating pancreatobiliary diseases. Single-session EUS and ERCP are considered to be essential in reducing the duration of hospital stays; however, complications are a primary concern. The aim of this study was to evaluate the safety and efficacy of single-session EUS and ERCP. Sixty-eight patients underwent single-session EUS and ERCP at a tertiary referral center between June 2008 and December 2012. We retrospectively reviewed patient data from a prospectively maintained EUS-ERCP database and evaluated the procedural characteristics and complications. Thirty-eight patients (56%) underwent diagnostic EUS, and 30 patients (44%) underwent EUS fine-needle aspiration, which had an overall accuracy of 100%. Sixty patients (89%) underwent therapeutic ERCP, whereas the remaining eight procedures were diagnostic. Thirteen patients underwent biliary stone extraction, and 48 underwent biliary drainage. The median total procedural time was 75 minutes. Complications were observed in seven patients (10%). Six complications were post-ERCP pancreatitis, which were resolved using conservative management. One patient developed Mallory-Weiss syndrome, which required endoscopic hemostasis. No sedation-related cardiopulmonary complications were observed. Single-session EUS and ERCP provided accurate diagnosis and effective management with a minimal complication rate.

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.

Rendimiento diagnóstico del marcador tumoral CA 19-9 en la diferenciación entre patología bilio-pancreática benigna y maligna / Accuracy of the tumor marker CA 19-9 in the differentiation of benign and malignant bilio-pancreatic diseases

Introduction: CA 19-9 has been identified as a derivative of sialic Lewis blood group A and is expressed in 95 percent of the population. Several studies have documented an overproduction of CA 19-9 in malignant pancreatic and biliary tree diseases. The objective of this study is to determine the accuracy of the tumor marker CA 19-9 differentiating benign and malignant bilio-pancreatic diseases. Material and Methods: diagnostic test study. We reviewed the records of all patients with malignant bilio-pancreatic diseases and benign biliary calculous diseases evaluated in Hospital Base Osorno between august 2007 and december 2011, with CA 19-9 as part of their study. Results: 71 patients met the inclusion criteria, 17 men and 54 women, with a mean age of 60.7 +/- 15.3 years old. Twenty nine (40.8 percent) cases were benign and 42 (59.2 percent) cases malignant. For a cutoff level of 37 U/ml the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to differentiate benign from malignant disease was 81 percent, 72.4 percent, 81 percent and 72.4 percent, respectively. For a cut off level of 130 U/ml specificity and PPV increased to 96.6 percent and 96.4 percent, respectively. Conclusions: the use of CA 19-9 is useful in the diagnosis of patients with suspected bilio-pancreatic malignant disease. The optimization of the normal published value can help to improve accuracy.

Introducción: El CA 19-9 se ha identificado como un derivado siálico del grupo sanguíneo Lewis A y se expresa en el 95 por ciento de la población. Numerosos estudios han documentado una sobreproducción de CA 19-9 en tumores malignos del árbol biliar y páncreas. El objetivo de este estudio es determinar la utilidad del marcador tumoral CA 19-9 en la diferenciación de patología bilio-pancreática benigna y maligna. Material y Métodos: estudio de pruebas diagnósticas. Se revisaron los antecedentes de todos los pacientes con patología bilio-pancreática maligna y enfermedad litiásica biliar benigna, evaluados en el Hospital Base de Osorno entre agosto de 2007 y diciembre de 2011, a los que se les haya solicitado CA 19-9 como parte de su estudio. Resultados: 71 pacientes cumplieron los criterios de inclusión, 17 hombres y 54 mujeres, con una media de 60,7 +/- 15,3 años de edad. Veintinueve (40,8 por ciento) casos correspondieron patología benigna y 42 (59,2 por ciento) casos a patología maligna. Para un valor de corte de 37 U/ml la sensibilidad, especificidad, valor predictivo positivo (VPP) y valor predictivo negativo (VPN) para diferenciar enfermedad benigna de maligna fue de 81 por ciento, 72,4 por ciento, 81 por ciento y 72,4 por ciento, respectivamente. Para un valor de corte de 130 U/ ml la especificidad y el VPP aumentaron a 96,6 por ciento y 96,4 por ciento, respectivamente. Conclusiones: el uso del Ca 19-9 es útil en el proceso diagnóstico de pacientes con sospecha de patología bilio-pancreática maligna. La optimización de los valores sobre el valor de normalidad publicado puede ayudar a mejorar su rendimiento.

Diagnóstico y tratamiento de las complicaciones biliares asociadas al trasplante hepático / Diagnosis and treatment of biliary complications associated with liver transplantation

Las complicaciones biliares se presentan en 10 - 25% de los pacientes que reciben un trasplante hepático y pueden causar una importante morbilidad e incluso la pérdida del injerto. Las complicaciones más comunes son la estenosis biliar (anastomótica y no anastomótica), fuga biliar y litiasis biliar. La gran mayoría de estas complicaciones puede tratarse con éxito mediante colangiopancreatografía retrógrada endoscópica. Esta revisión se centra en el diagnóstico, factores de riego y tratamiento endoscópico de las complicaciones biliares asociadas al trasplante hepático

Biliary complications ocurr in 10 - 25% of liver transplant recipients and are associated to a significant morbidity and the possibility of graft failure. The most common biliary complications are strictures (both anastomotic and non-anastomotic), bile leaks and stones. Most of these complications can be appropriately managed with endoscopic retrograde cholangiopancreatography. This article will review the diagnosis, risk factors, and endoscopic management of biliary complications related to liver transplantation

Colangiopatía asociada a SIDA: cuando la sola imagen no basta / AIDS cholangiopathy: when images in isolation are not enough

In HIV-infected patients, liver and biliary tract may be affected by different entities, such as AIDS-cholangiopathy, which is usually associated with CD4+T lymphocytes count below 100 cells/mm³ along with non-specific symptoms. Although imaging studies play a major diagnostic role they should always be evaluated according to patients clinical context. While ultrasound and CT scans provide relevant diagnostic information, specialized studies such as MRI and MRCP have become increasingly valuable due to their ability to demonstrate parietal as well as stenotic biliary changes. Despite ERCP remains the gold-standard for diagnosis of AIDS-related cholangiopathy, currently it is usually reserved to clearly exclude the presence of malignancy, or as a specific invasive therapeutic procedure, when indicated.

En pacientes infectados con VIH, el hígado y las vías biliares pueden presentar compromiso de distinta índole. Dentro de éstos, la colangiopatía asociada al SIDA se presenta con una sintomatología más bien inespecífica y habitualmente con recuentos de linfocitos T CD4 <100/mm³. En este escenario, si bien los estudios de imagen juegan un rol muy relevante, éstos siempre deben ser evaluados en relación al contexto clínico del paciente. Si bien la ecografía y la TC aportan valiosa información en el diagnóstico, en la actualidad la resonancia magnética de abdomen combinada con colangioresonancia tienen gran utilidad, por ser capaces de demostrar tanto las alteraciones parietales, como los cambios morfológicos estenóticos biliares de esta patología. Si bien la ERCP aún conserva su valor de gold standard para el diagnóstico, actualmente la tendencia se dirige a reservarla para el descarte de neoplasias, en casos dudosos o como procedimiento terapéutico invasivo específico, cuando sea indicado.

Role of Fully Covered Self-Expandable Metal Stent for Treatment of Benign Biliary Strictures and Bile Leaks

Endoscopic therapy by balloon dilation and placement of multiple large-bore plastic stents is the treatment of choice for benign biliary stricture. This approach is effective but it typically requires multiple endoscopic sessions given the short duration of stent patency. The endoscopic approach for treatment of bile leak involves the placement of a stent with or without biliary sphincterotomy. The self-expandable metal stent (SEMS) has traditionally been used for palliation of malignant biliary strictures given the long duration of stent patency owing to their larger stent diameter. Recently, SEMS has been used in a variety of benign biliary strictures and leaks, especially with the design of the covered self-expandable metal stent (CSEMS), which permits endoscopic-mediated stent removal. The use of CSEMS in benign biliary stricture could potentially result in a decrease in endoscopic sessions and it is technically easier when compared to placement of multiple plastic stents. However, complications such as cholecystitis due to blockage of cystic duct, stent migration, infection and pancreatitis have been reported. The potential subsegmental occlusion of contralateral intrahepatic ducts also limits the use of CSEMS in hilar stricture. Certain techniques and improvement of stent design may overcome these challenges in the future. Thus, CSEMS may be appropriate in only highly selected conditions, such as refractory benign biliary stricture, despite multiple plastic stent placement or difficult to treat bile duct stricture from chronic pancreatitis, and should not be used routinely. This review focuses on the use of fully covered self-expandable metal stent for benign biliary strictures and bile leaks.

Fully Covered Self Expandable Metal Stent for the Treatment of Benign Biliary Strictures / 대한소화기학회지

No abstract available.

Prevalencia de complicaciones biliares en colecistectomias realizadas en el Hospital Miguel Pérez Carreño en el período 2006-2009 / Prevalence of bile duct injuries after cholecystectomy performed at Hospital Miguel Pérez Carreño during 2006-2009

Las lesiones de vías biliares ocurren en un 0,2% a 1,4% de los pacientes sometidos a colecistectomías laparoscópicas, y 0,3% en las colecistectomías abiertas. La colangiopancreatografia retrograda endoscópica (PCRE) se ha convertido en una técnica de amplia utilidad terapéutica para el manejo de estas lesiones. La mayoría de las lesiones de vías biliares pueden ser tratadas de manera exitosa (en un 70-95% de los pacientes) con intervenciones endoscópicas. En el periodo 2006-2009 se han realizado en este centro 1089 colecistectomías, 486 por vía convencional y 600 vía laparoscópica. Determinar la prevalencia de complicaciones post quirúrgicas de las vías biliares, mediante PCRE, y el tipo de tratamiento realizado endoscópico o quirúrgico. Se revisaron historias clínicas y base de datos de la unidad de gastroenterología, realizándose un análisis retrospectivo, descriptivo, transversal. Se utilizo la escala de clasificación de las lesiones biliares post quirúrgica de Amsterdam. Se registraron 20 casos de lesiones postquirúrgicas de vías biliares. La técnica de colecistectomía convencional fue realizada en un 50% (N=10), la laparoscópica en un 40%(N=8). La lesión biliar más frecuente fue la tipo A en un 35% (N=7), la tipo B se presento en un 25% (N=5). y la tipo D en un 30% (N=6). La esfinterotomía endoscópica se realizo en un 70% de los pacientes (N=14). La colocación de prótesis biliar se practicó en un 55% (N=11), y requirieron tratamiento quirúrgico solo un 20% de los casos (N=5). La lesión postquirúrgica más frecuente fue la lesión biliar tipo A. El tratamiento endoscópico probó ser el tratamiento de elección y el más aplicado...

Bile duct injuries occur in 0,2% to 1,4% of patients following laparoscopic cholecystectomy and, in 0,3% in open cholecystectomy. Endoscopic retrograde cholangiopancreatography (ERCP) has become a broadly useful therapeutic technique for the treatment of these lesions. The majority of bile duct injuries can be successfully treated endoscopically in 70-95% with ERCP. One thousand eighty-nine (1089) cholecystectomies have been performed in this institution during 2006-2009; 486 open and 600 laparoscopic cholecystectomies. To determine the prevalence of post-surgical bile duct injuries by ERCP, and the type of treatment performed, endoscopic or surgical. The clinical records and database of the Gastroenterology Division; carrying out a retrospective, transversal and descriptive study. The system used to determine the type of injury was the Amsterdam post-surgical bile duct injuries rating scale. Twenty (20) cases of bile duct injury following laparoscopic or conventional cholecystectomy were registered. Conventional cholecystectomy was performed in 50% of patients (N=10), laparoscopic in 40%. The mostfrequent biliary lesions were: type A in 35% (N=7), type B in 25% (N=5) and, type D in 30% (N06). Endoscopic sphincterotomy was performed in 70% of patients (N=14). Biliary prosthesis placement was performed in 55% (N=11) and, 20% (N=5) of the cases needed surgical treatment. The mostfrequent post-surgical bile duct injury was biliary lesion type A. Endoscopic treatment proved to be the most performed, and the treatment of choice...

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.

Medios de diagnóstico aplicados para la confirmación de enfermedades hepatobiliares / Diagnosis means for the confirmation of hepatobiliary diseases

Se realizó un estudio descriptivo y transversal en dos salas de Medicina Interna y en la sala de Gastroenterología Clínica del Hospital General Docente Dr Juan Bruno Zayas Alfonso de Santiago de Cuba, desde febrero del 2006 hasta igual período del 2007, con vista a disminuir la repercusión negativa de las enfermedades hepatobiliares sobre el funcionamiento orgánico en general. Las fuentes de información utilizadas fueron la historia clínica y los registros estadísticos. Las pruebas serológicas fueron las más utilizadas y con mayor efectividad en el diagnóstico de estas afecciones. Predominaron las enfermedades de localización hepática y la mayoría por causas infecciosas.

A descriptive and cross-sectional study was carried out in two rooms of Internal Medicine and in the Clinical Gastroenterology room at Dr Juan Bruno Zayas Alfonso Teaching General Hospital of Santiago de Cuba, from February, 2006 to February, 2007, with the purpose of decreasing negative implication of hepatobiliary diseases on organic functioning in general. The used sources of information were medical and statistical records. Serological tests were the most used and more effective in the diagnosis of these conditions. Hepatic diseases prevailed and most of them due to infectious causes.

Hepatobiliary tuberculosis in western India.

Tuberculous involvement of liver as a part of disseminated tuberculosis is seen in up to 50-80% cases, but localized hepatobiliary tuberculosis (HBTB) is uncommonly described. During 6 years, a total of 280 consecutive patients with TB were evaluated prospectively for the presence and etiology of liver involvement. Cases with miliary TB or immunosuppression and cases receiving anti-tuberculosis drugs prior to presentation to our unit were excluded (38 cases). Details of clinical, biochemical and imaging findings and histology/microbiology were noted. Of 242 included cases, 38 patients (15.7%; age 38.1 +/- 12.5 years; sex ratio 2.5:1) had HBTB, whereas 20 patients (9%; age 39.3 +/- 16.3 years; sex ratio 2.1:1) had other liver diseases. Diagnosis of HBTB was based on caseating granuloma on histology (18/23 procedures), positive smear/culture for acid-fast bacilli (21/39 procedures) and positive polymerase chain reaction for Mycobacterium tuberculosis (28/29 procedures) when diagnostic procedures were guided by imaging results. Thirty-eight cases with HBTB were classified as follows [patients (n), (%)]: (A) hepatic TB [20 (52.6%)]: (1) granulomatous hepatitis - 10 (26.3%), (2) liver abscesses or pseudotumors - 10 (26.3%) and (3) calcified hepatic granuloma - 0 (0%); (B) biliary TB [15 (39.4%)]: (1) biliary strictures - 2 (5.2%), (2) gall bladder involvement - 1 (2.6%) and (3) biliary obstruction due to lymph node masses - 12 (31.5%); (C) mixed variety [3 (7.8%)]: (1) simultaneous granulomatous hepatitis and biliary stricture - 1 (2.6%) and (2) simultaneous lymph node involvement and calcified hepatic granuloma - 2 (5.2%). All the cases responded well to standard anti-tuberculosis therapy. HBTB forms an important subgroup in TB cases. It requires a combination of imaging, histological and microbiological procedures to define the diagnosis. HBTB responds well to treatment.

Carcinoma gall bladder : an institutional experience.

This is a retrospective study of histologically proven cases of carcinoma of the gall bladder presenting to Bhaktapur Cancer Hospital and Om Hospital and Research center, Nepal, over a period of four years, from January 1999 to December 2003. The aim of this study was to review outcome of management and staging of cancer of gall bladder presenting to a specialist cancer centre. Sixty Eight patients presented over this time period; 57% presented with biliary tract symptoms and 49% had a history of chronic cholelithiasis. Twenty one patients presented with apparently resectable disease, but only those undergoing radical surgery demonstrated long term survival. Adjuvant therapies did not have any influence on outcomes. Palliative treatments, notably chemotherapy, showed some response. Besides radical surgery in truly operable cases, current treatments make little impact on this disease. Gall bladder cancer is one of the common biliary tract malignancy and demonstrates marked geographical variation. Its incidence appears to be reasonably common in Nepal. Treatment options have limited efficacy. Randomised data is urgently needed and a number of potential trials are suggested.

Correlación ecográfico-quirúrgica en patología benigna de la vía biliar / Ultrasonographic-surgical correlation in benign bile duct

Introducción: La ecografía es un método eficaz, no invasivo y accesible para el diagnóstico de patologías de la vía biliar. Objetivo: Analizar la correlación entre las imágenes ecográficas y los hallazgos intraoperatorios en una serie consecutiva de pacientes con patología benigna de la vía biliar. Lugar de aplicación: Hospital Público de alta complejidad. Material y métodos: Se realizó un estudio descriptivo y retrospectivo del período comprendido entre diciembre 2003 y diciembre 2004. Se incluyeron 278 pacientes (113 hombres y 165 mujeres) con una edad promedio de 39 años. Todos presentaron añgún tipo de patología benigna de la vía biliar. Se analizaron las ecografías de los pacientes con litiasis vesicular, litiasis coledociana, colecistitis aguda y síndrome de hipertensión biliar y se efectuó la correlación con los hallazgos intraoperatorios, macroscópicos y colangiográficos. Resultados: Hubo correlación ecográfico-intraoperatoria en el 84,2% de los casos (234 pacientes). En los casos de síndrome de hipertensión biliar como diagnóstico de ingreso se observó el mayor porcentaje de errores. Conclusiones: La ecografía preoperatoria para el diagnóstico de la patología benigna de la vía biliar mostró en esta serie una aceptable correlación con los hallazgos intraoperatorios. La patología canalicular presentó mayores dificultades para su diagnóstico.

Análise do papel da colangiopancreatografia retrógrada endoscópica (CPRE) como método terapêutica na terceira idadé / Analysis of the role of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic method for the elderly

Introdução: Tem-se observado mudança demográfica im»portante nas sociedades ocidentais decorrente do aumento da expectativa de vida, com aumento progressivo do número de pacientes idosos. Paralelamente a isso, observou-se incidência aumentada de afecções das vias biliares, particularmente a doen»ça litiásica e as suas complicações nesse grupo populacional. A Baixada Santista atrai a população idosa por ser uma região que detém o segundo melhor índice de desenvolvimento social do Estado de São Paulo (IEME-2002) e o terceiro melhor índice de desenvolvimento humano do Estado, ocupando o quinto lugar no Brasil, segundo o Programa das Nações Unidas para o Desenvolvimento - PNUD. Objetivo: O presente estudo objeti»vou avaliar e discutir o impacto da colangiopancreatografia re»trógrada endoscópica (CPRE) como método diagnóstico e tera»pêutico das afecções biliodigestivas em pacientes idosos na Baixada Santista. Métodos: Foram analisados retrospectivamente dados referentes a 247 pacientes submetidos a CPRE no HAC»Santos, no período de janeiro de 2003 a janeiro de 2006, con»siderando-se como variáveis: sexo, idade, etnia, indicações, diag»nósticos obtidos, procedimentos realizados, complicações relacionadas ao procedimento e mortalidade, enfatizando-se os dados em pacientes idosos (acima de 60 anos de idade). Resul»tados: Considerando-se os idosos, verificou-se que a CPRE foi realizada em 146 (62,9%) do total de pacientes efetivamente estudados (232). As principais indicações para o procedimento foram a suspeita de coledocolitíase em 122/232 (52,7%), icterí»cia obstrutiva em 86/232 (37%) e pancreatite aguda em 24/ 232.

Comparison of Clinical Characteristics between Cryptogenic and Biliary Pyogenic Liver Abscess / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to evaluate the characteristics of cryptogenic and biliary pyogenic liver abscess by comparing the clinical aspects between the two groups. METHODS: Of 119 patients treated for pyogenic liver abscess from 2000 to 2004, 82 subjects with cryptogenic liver abscess and 21 with biliary abscess were analysed retrospectively. RESULTS: There were no significant differences between the two groups regarding clinical symptoms. The characteristics of abscess were similar except the size of abscess. The size of abscess less than 5 cm in diameter was more common in billiary group than in cryptogenic group (p=0.004). Compare to cryptogenic group, biliary group had more positive culture test from abscess (100% vs. 69%, p=0.006). Especially, E. coli isolated from abscess culture (28% vs. 7%, p=0.014) and blood culcure (23% vs. 4%, p=0.035) were more common in biliary group than in cryptogenic group. There was no difference in mortality between the two groups (biliary vs. cryptogenic: 4.8% vs. 0%, p=0.204). However, the rate of clinical improvement was higher in cryptogenic group than in biliary group (92.7% vs. 66.7%, p=0.001). CONCLUSIONS: Biliary liver abscess had similar clinical characteristics to cryptogenic origin. Biliary liver abscess had smaller abscess size and more positive abscess culture rates than cryptogenic abscess. Improvement rate without complication and recurrence was higher in cryptogenic group than biliary group.

Biliary ascariasis: the value of ultrasound in the diagnosis and management

Conventional methods of radiographic examination are often unsatisfactory for identifying worms in the biliary tract. Ultrasonography is a non-invasive, quick and safe procedure known to have diagnostic accuracy. We studied the ultrasonographic appearances of biliary ascariasis and the role of ultrasonography in diagnosis and management. In a prospective 5-year study, a sonographic diagnosis of biliary ascariasis was made on 46 Yemeni patients. The diagnosis was based mainly on sonographic appearances supported by clinical and laboratory results and proved by outcome of either surgical or medical management or spontaneous exit of worms. Follow-up ultrasound was performed for all patients to confirm the diagnosis and to monitor management. Parasites were present in the dilated main bile duct in 23 patients, in the gallbladder in 12 patients, in the intrahepatic ducts in 6 patients, in the main pancreatic duct in 4 patients and as an intrahepatic abscess in one patient. The characteristic appearance of Ascaris lumbricoides was as single or multiple echogenic nonshadowing linear or curved strips with or without echoic tubular central lines that represent the digestive tracts of the worm. A spaghetti-like appearance was seen in 9 patients and amorphous fragments were seen in 2 patients. Sixteen patients underwent surgery, 20 patients were treated medically [including spontaneous exit of the worm in 7 patients without treatment] and in 10 patients worms were extracted by endoscopic retrograde cholangiopancreatography. Follow-up ultrasound was found to be effective in confirming the diagnosis and monitoring management