Magnetic resonance cholangiopancreatography in the diagnosis of primary sclerosing cholangitis.

BACKGROUND AND STUDY AIMS: Magnetic resonance cholangiopancreatography (MRCP) is a less-invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of primary sclerosing cholangitis (PSC). This study evaluated the diagnostic accuracy of MRCP in PSC compared with ERCP, and assessed the diagnostic accuracy of different T2w sequences. PATIENTS AND METHODS: 95 patients (69 PSC, 26 controls) were evaluated using both ERCP and MRCP. Exclusion criteria included secondary sclerosing cholangitis and contraindications to MRCP. The diagnosis of PSC was confirmed in 69 patients based on ERCP as the reference gold standard. MRCP was performed using a 1.5 Tesla MR unit, using breath hold, coronal and transverse half-Fourier acquisition single-shot turbo spin-echo (HASTE), coronal-oblique, fat-suppressed half-Fourier rapid acquisition with relaxation enhancement (RARE), and coronal-oblique, fat-suppressed, multisection, thin-section HASTE (TS-HASTE) sequences. The MRCP morphological criteria of PSC were evaluated and compared with ERCP. RESULTS: The sensitivity, specificity, and diagnostic accuracy were 86%, 77%, and 83%, respectively, using the MRCP-RARE sequence, and increased further to 93%, 77%, and 88%, respectively, by the inclusion of follow-up MRCP in 52 patients, performed at 6-12-month intervals. HASTE and TS-HASTE sequences showed significantly lower diagnostic accuracy but provided additional morphologic information. CONCLUSIONS: MRCP can diagnose PSC but has difficulties in early PSC and in cirrhosis, and in the differentiation of cholangiocarcinoma, Caroli's disease, and secondary sclerosing cholangitis. A positive MRCP would negate some diagnostic ERCP studies but a negative MRCP would not obviate the need for ERCP.

[Detection of liver lesions with gadolinium-enhanced VIBE sequence in comparison with SPIO-enhanced MRI]. / Detektion von Leberläsionen mit der Gadolinium-verstärkten VIBE-Sequenz im Vergleich zur SPIO-verstärkten MRT.

PURPOSE: Detection of malignant liver lesions with gadolinium-enhanced volumetric interpolated breath-hold examination (VIBE) in comparison with SPIO-enhanced MRT (four different SPIO-enhanced T2w sequences) and histological and imaging follow-up in non-cirrhotic livers at 1.5 T. PATIENTS AND METHODS: Twenty-two patients with suspected focal liver lesions prospectively underwent a gadolinium-enhanced 3D VIBE. Four T2w sequences (HASTE sequence, fast spin-echo-sequence with and without fat-saturation, FLASH 2D gradient echo-sequence) after administration of superparamagnetic iron oxide (SPIO) served as gold standard combined with histological work-up in 17 patients and histological and imaging follow-up in five patients. The image quality was evaluated and the detectability of intrahepatic lesions was rated by the alternative free-response receiver operating characteristic (AFROC) analysis. In addition, the contrast-to-noise ratio was compared. RESULTS: Altogether 49 malignant and 35 benign liver lesions were found. Concerning the image quality, VIBE turned out to be of slightly poorer image quality than the SPIO-enhanced examination with HASTE sequence (4.95 vs. 5.0). The fast spin-echo-sequence without fat-saturation demonstrated the highest contrast-to-noise ratio. All sequences showed a comparable certainty in detecting lesion (area under the curve 0.68-0.73) and identifying malignant liver lesions. CONCLUSION: Despite the small number of patients, VIBE seems to be a comparable, inexpensive and fast method in diagnosing malignant liver lesions.

Carbohydrate-deficient transferrin: diagnostic efficiency among patients with end-stage liver disease before and after liver transplantation.

We tested the diagnostic validity of carbohydrate-deficient transferrin (CDT) as an indicator for relapse into elevated alcohol consumption among patients who were examined under follow-up treatment before (n = 147) and after (n = 102) orthotopic liver transplantation (OLT) in the outpatient-department of the University Hospital Department of Surgery in Hamburg-Eppendorf. CDT measurements were performed with two commercial kits in parallel (CDTect-RIA and CDT%-RIA). Short-term parameters of alcohol consumption (ethanol, methanol) indicated relapses into elevated alcohol consumption in 11.4% of the evaluated patients with alcoholic liver disease (ALD) before transplantation. Before OLT, median CDT values were determined to be elevated among patients with alcoholic as well as nonalcoholic end-stage liver diseases (NALD). Among patients with ALD, we found elevated CDT medians even in those who were successfully scheduled for OLT after long-term evidence of abstinence proved by biochemical short-term parameters and psychological tests. Both CDTect and CDT% assays had comparable low specificities in selected patient groups before transplantation. CDT% and CDTect were negatively correlated with the albumin level. Before the study ended, CDT was no longer implemented in the evaluation of whether an OLT should be administered. This was due to inconsistent results of CDT in ALD as well as NALD. After OLT, patients with ALD, as well as NALD, had statistically significant lower CDT medians than before OLT, which ranged within reference levels. We determined, according to CDT, elevated alcohol consumption subsequent to OLT in 4 of 13 patients with ALD who underwent transplantation during the study (median observation period: 10 months). CDT does not appear to be useful in evaluating patients before OLT. With regained specificity and high sensitivity in patients after OLT, CDT could be recommended as a standard instrument for quality control in patients with ALD after liver transplantation.

One year of experience with extended application and modified techniques of split liver transplantation.

As organ donation rates decreased in Europe, the authors started a systematic approach of liver splitting in their center in 1994. During this 1-year experience, 73 cadaveric liver transplantations were performed in 66 patients. Sixteen of these transplantations were the result of split-liver transplantation (21.9% of grafts, 24.2% of patients). Patient and graft survival rates at 3 months were 81.2% and 75%, compared with 89.1% and 76.9 % for whole organs. Two modified techniques were developed, based on the technique of living related liver procurement, and applied in 10 cases. With these new techniques, patient and graft survival rates were 90% and 90%. This systematic approach allowed the total number of transplantations in our program to be maintained, despite the decrease in organ availability.

[Bile duct carcinoma after abdominal irradiation for urologic malignancies]. / Gallengangkarzinome nach abdomineller Bestrahlung urologischer Malignome.

Malignancies of the biliary tract are rare diseases. Tumor inductions after radiotherapy are reported in several papers. We report about 3 cases with consecutive biliary tract carcinoma 18-32 years after manifestation of an urogenital carcinoma. All 3 patients (52-63 years) were treated with additive radiotherapy after surgical-urological therapy. Icterus was the top-ranging symptom of this secondary carcinoma. In 2 of the 3 cases surgical tumor resection was performed (biliary duct resection with central liver resection; pancreatico-duodenectomy). Because of the bad general condition of health the third patient got only a biopsy of the tumor. All patients died within 2 years after diagnosis. The accidental accumulation of the rare biliary tract carcinoma after urogenital malignancies in our collection of clinical cases (2 seminoma; 1 bladder tumor) give rise the question about the causal association between primary carcinoma, additive therapy and the development of secondary carcinoma.

[T-cell oriented therapy concept in the treatment of rejection following liver transplantation]. / T-Zell-orientiertes Therapiekonzept in der Rejektionsbehandlung nach Lebertransplantation.

Since 1984 32 liver transplantations were performed at the University of Hamburg in 29 patients. 2-year survival rate of electively grafted patients is 71.4%. Immunosuppression is performed with ciclosporin A, steroids and azathioprine. The diagnosis of rejection episodes or viral infections is established by determination of activated lymphocytes, lymphoblasts or LGL-cells in the peripheral blood or in the graft (aspiration cytology). Additional liver biopsy gives information regarding the extent and kind of a white blood cell infiltrate and furthermore allows a differentiation of T-lymphocytes by immunohistological staining. Rejection episodes are primarily treated with ATG (Fresenius), non responding cases either with ATG (Stanford) or OKT 3. Successful treatment with ATG results in an elimination of T3, T4 and T8-lymphocytes. A sufficient result of OKT 3 treatment is stated after elimination of T3 cells.

[Significance of the urodynamic study in the diagnosis of urinary incontinence in women]. / Stellenwert der urodynamischen Untersuchung bei der Abklärung der weiblichen Harninkontinenz.

Comparing the results of clinical evaluations and urodynamic studies in 175 consecutive incontinent females, we came to different diagnoses in 12.6%. If we rely only on the clinical diagnosis, this means that at least 1 out of 10 incontinent females with no urodynamic work-up will have a wrong or incomplete therapy. In respect to the exact indication, especially for operative therapy, urodynamic work-up seems therefore necessary in different forms of female urinary incontinence.