Composite tumor of the main bile duct producing several regulatory peptides.

Herein we describe what is, to our knowledge, the first reported case of a composite tumor of the main bile duct with epiploon metastases. Glucagon, pancreatic polypeptide, and somatostatin-immunoreactive cells were demonstrated in these metastases, but not serotonin, gastrin, or insulin-immunoreactive cells. The clinical significance of the neuroendocrine cells in the present case is discussed.

[Endoscopic sphincterotomy in choledocholithiasis: analysis of an experience of 530 interventions]. / Esfincterotomia endoscópica na coledocolitíase: análise de uma experiência de 530 intervenções.

We report the experience of 530 consecutive cases of choledocolithiasis treated through Endoscopic Sphincterotomy (ES) between January 1980 and January 1988 (74% of total patients submitted to ES in the same period). 73% had more than 60 years and 47% more than 70 years. A slight majority (52%) had previous cholecystectomy (1/3 still with T-tube drainage) and the remaining had gallbladders insitu (lithiasic in 82%). Therapeutic goals (achieved drainage and complete stone removal) have been achieved in 95% of patients with a low immediate morbidity (9%) and mortality (1%). Delayed mortality, until 30th day (3%) includes 6 cases of obstructive cholangitis with sepsis, unaltered by emergent ES. Follow-up showed a 3% incidence of reintervention from restenosed ES. Patients with lithiasic gallbladder had a 33% cholecistectomy rate, mostly elective during first month post-ES. Our experience confirms ES as an efficient and safe routine treatment for choledocolithiasis. It should be the first choice in patients with previous cholecystectomy or alithiasic gallbladder and a largely applicable tool in those with associated gallbladder stones. Decision about post-ES cholecystectomy in these patients must be weighed on clinical grounds and according to surgical risk groups.

Combined approach to the differential diagnosis of cholestatic jaundice with endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, ultrasonography, and liver biopsy.

A prospective study of 33 patients with cholestatic jaundice was performed with combined use of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), ultrasonography, and liver biopsy. A higher rate of success with PTC in 25 cases of extrahepatic cholestasis was offset by the better score of ERCP in 8 cases of intrahepatic cholestasis and its wider diagnostic scope. The procedures were complementary in 10 cases. Ultrasonic imaging of intrahepatic bile ducts proved useful for selecting the first cholangiographic technique. Liver biopsy established etiology in intrahepatic cholestasis. Our combined approach allowed us to develop through objective criteria a diagnostic flow chart of cholestasis.