Tuberculous lymphadenitis as a cause of obstructive jaundice: a case report and literature review.

Obstructive jaundice secondary to tuberculosis (TB) is extremely rare. It can be caused by TB enlargement of the head of the pancreas, TB lymphadenitis, TB stricture of the biliary tree, or a TB mass of the retroperitoneum. A 29-year-old man with no previous history of TB presented with abdominal pain, obstructive jaundice, malaise and weight loss. Ultrasonography (US), computer tomography (CT) scan and endoscopic retrograde cholangiopancreatography (ERCP) were suggestive of a stenosis of the distal common bile duct (CBD) caused by a mass in the posterior head of the pancreas. Tumor markers, CEA and CA19-9 were within normal limits. At operation, an enlarged, centrally caseous lymph node of the posterior head of the pancreas was found, causing inflammatory stenosis and a fistula with the distal CBD. The lymph node was removed and the bile duct resected and anastomosed with the Roux-en Y jejunal limb. Histology and PCR based-assay confirmed tuberculous lymphadenitis. After an uneventful postoperative recovery, the patient was treated with anti-tuberculous medication and remained well 2.5 years later. Though obstructive jaundice secondary to tuberculous lymphadenitis is rare, abdominal TB should be considered as a differential diagnosis in immunocompromised patients and in TB endemic areas. Any stenosis or fistulation into the CBD should also be taken into consideration, and biliary bypass surgery be performed to both relieve jaundice and prevent further stricture.

Concomitant cholecystoduodenal fistula and cholecystocholedochal fistula due to actinomyces.

This report describes a patient with a cholecystoduodenal fistula and cholecystocholedochal fistula who was found to have Actinomyces contained within the gallbladder upon pathologic examination. The cholecystocholedochal fistula was repaired using a flap of gallbladder over a T-tube, and the actinomycosis was successfully eradicated with 6 weeks of intravenous doxycycline followed by an additional 6 months of oral doxycycline.

Risk of postoperative infection in patients with bactibilia undergoing surgery for obstructive jaundice.

BACKGROUND: This study was performed to investigate the relationship between bactibilia and postoperative infection in patients undergoing surgery for obstructive jaundice. METHODS: With IRB approval, we prospectively examined 76 patients undergoing surgery for obstructive jaundice. It was the routine practice of the surgeons performing the operations to culture the common bile duct bile (CBDB). Rates of postoperative infection were analyzed with regard to the effect of positive bile cultures and biliary instrumentation preoperatively. RESULTS: Seventy-one patients had CBDB cultures, 16 of whom had bactibilia. Bactibilia was present in 15 of 47 (33%) who had preoperative ERCP versus one of 24 (4%) of those without preoperative ERCP (p = 0.0075). Postoperative infection, including pneumonia, bloodstream, central venous catheter, surgical site, intraabdominal, and urinary tract infection, occurred in six of 16 (38%) of those with bactibilia versus four of 55 (7%) of those without bactibilia (p = 0.0071). CONCLUSIONS: Preoperative ERCP was associated with an approximately eightfold increase in the likelihood of having culture-positive bile at the time of surgery for obstructive jaundice. Additionally, culture-positive bile at the time of surgery was associated with a greater than fivefold incidence of postoperative infection.

Parapapillary choledochoduodenal fistula associated with cholangiocarcinoma.

Parapapillary choledochoduodenal fistula is a rare disorder. We herein report a case of parapapillary choledochoduodenal fistula associated with cholangiocarcinoma. A 61-year-old woman was admitted to our hospital for further examination of a liver tumor. She had no clinical symptoms, but computed tomography scans showed an irregularly contoured liver tumor which was histologically confirmed to be adenocarcinoma, by a needle biopsy examination. Duodenal fiberscopy revealed a fistula orifice 1.0 cm proximal to the orifice of the papilla of Vater, and endoscopic retrograde cholangiography through the fistula showed a communication to the common bile duct. Hypotonic duodenography demonstrated reflux of contrast material into the choledochoduodenal fistula. The bile sample collected from the common bile duct showed extremely high levels of pancreatic enzymes, including amylase, phospholipase-A2, and elastase-I. Furthermore, Helicobacter DNA was detected in bile by polymerase chain reaction (PCR) analysis. This experience suggests to us that parapapillary choledochoduodenal fistula may be a risk factor for biliary tract carcinoma, and surgical management is the treatment of choice for this rare condition, even when the patient has no significant clinical symptoms.

Helicobacter species are not detectable by 16S rDNA PCR in bile from Dutch patients with common bile duct stones.

BACKGROUND: Some Helicobacter species colonize the intestinal tract. To explore the possible relation between Helicobacter spp. and gallbladder disorders, we have investigated their presence in bile of patients with biliary obstruction and dilatation of the bile ducts. METHODS: Bile was sampled from 31 Dutch patients with biliary obstruction identified by jaundice and dilatation of the bile ducts on ultrasound. Samples (n = 31) were obtained immediately following cannulation of the common bile duct (CBD) by endoscopic retrograde cholangiopancreatography (ERCP) (n = 29) or by peri-operative puncture of the gallbladder (n = 2). DNA was isolated from bile by binding to diatoms. Helicobacter spp. were detected by a sensitive (detection limit 1 CFU per reaction tube) 16S rDNA PCR with genus-specific primers. Duplicate samples were spiked with Helicobacter pylori DNA and subjected to PCR in order to check for inhibition. RESULTS: 28 patients had CBD stones (bile collected by ERCP (n = 26) or operatively (n = 2)), 2 had a pancreatic head tumor, and in 1 no abnormalities were found. In 1 of 21 amplifiable bile samples (10/31 inhibited) from Dutch patients with CBD stones, H. pylori 16S rDNA was found. CONCLUSION: Our data indicate that CBD stones in Dutch patients are not associated with the presence of Helicobacter spp. in bile.

Polyethylene stent blockage: a porcine model.

BACKGROUND: Endoscopic insertion of biliary stents is a useful treatment for obstructive jaundice resulting from unresectable tumors of the pancreas and biliary tree. The main drawback is the recurrence of jaundice due to clogging. The aim of this study was to establish an experimental model of polyethylene stent clogging in large white pigs. METHODS: A straight polyethylene stent of 5F (group I), 7F (group II) or 10F size (group III) was inserted in the common bile duct. Animals were killed at 2 months, or earlier if physical signs suggesting stent clogging occurred. Chemicophysical analysis of stent deposition combined stereomicroscopy and identification of the contents by means of Fourrier transform infrared spectroscopy. Bacteriologic analyses included identification of aerobic and anaerobic bacteria and measurement of beta-glucuronidase, lecithinase and lipase activities. RESULTS: Physical signs suggesting stent obstruction or death occurred in 8 of 8 animals in group I, 11 of 12 in group II, and 2 of 8 in group III (p < 0.001). The proportion of mucoprotein in the stent contents tended to fall with increasing stent diameter (mean 82%, 58% and 47% for 5F, 7F and 10F, respectively), whereas wheat starch and calcium bilirubinate content increased with increasing stent diameter (9% and 4%, 18% and 10%, and 29% and 23% for 5F, 7 F, and 10F, respectively), although none of these differences were statistically significant. A variety of bacteria were cultured from the stent deposits, including anaerobic strains. Clostridium species were associated with the highest enzyme activities. CONCLUSIONS: In this model the major component of early stent deposits was mucoprotein, and numerous aerobic and anaerobic bacteria were isolated. Formation of calcium bilirubinate was a late phenomenon and poorly related to bacterial enzymatic activities.

Hepatic mitochondrial changes in experimental obstructive jaundice complicated by biliary infection.

The effects of biliary infection on the structural and functional changes in the liver in obstructive jaundice was studied using rats as experimental animals. Biliary infection with obstructive jaundice was induced in the animals by injecting Escherichia coli into the common bile duct through a nylon tube cannulated into the duct. This was followed by the clamping of the tube. For the controls, the tube was clamped in the absence of Escherichia coli. After 3, 7, 14 and 21 days, the animals were sacrificed, and some serum enzyme activities, histological changes in the liver, and the coupling efficiency of mitochondria isolated from the liver were investigated. The phosphorylating ability of hepatic mitochondria was more seriously affected when the obstruction was complicated by cholangitis. We suggest that, when associated with obstructive jaundice, biliary infection should be carefully treated prior to hepatectomy.

Effect of biliary infection on common bile duct healing in the rat.

It has been postulated that biliary infection plays a role in bile duct stricture formation. The aim of this study was to verify this hypothesis and to evaluate the effect of biliary infection on common bile duct healing. A 3-mm longitudinal choledochotomy was performed in 120 rats and closed with a continuous 11/0 Ethilon suture. Common bile duct division with end-to-end anastomosis using interrupted 11/0 Ethilon sutures was performed in another 30 rats. Biliary infection was achieved in half of the animals with retrograde injection of living 046:K1:H31 strain Escherichia coli recovered from the rat colonic content. All rats with choledochotomy, including those with biliary infection, showed no bile leakage at the suture line, and the bursting pressure at the site of choledochotomy exceeded 40 mmHg as early as 24 h. Rats with common bile duct anastomosis alone showed no stricture formation for up to 6 months after operation. All rats with biliary sepsis developed complete occlusion at the anastomosis. On scanning electron microscopy, the biliary epithelium was well preserved in all rats. The study suggests that in rats with biliary sepsis the risk of bile leakage after primary closure of the common bile duct is negligible, but biliary infection may play a critical role in common bile duct stricture formation.

A rat model for sepsis in chronic biliary obstruction.

The effect of retrograde intrabiliary (RI) injection of E. coli was studied in Sprague-Dawley rats with and without chronic biliary obstruction. The challenge dose of E. coli was standardized by the use of frozen (-80 degrees C) aliquots of bacteria. Injection of 10(2), 10(5) or 10(8) colony-forming units (CFU), respectively, into three groups of 8 normal rats, immediately after occlusion of the common bile duct (CBD), did not kill any of the animals. In contrast, 5 of 8 animals with chronic biliary obstruction died from E. coli sepsis after RI injection of 10(2) bacteria (p less than 0.05). Furthermore, all of 4 obstructed animals died after challenge with 10(5) CFU (p less than 0.01), as compared to the 8 normal rats surviving this dose. Intraperitoneal injection of 10(5) E. coli did not kill any of 6 animals with 3 weeks biliary obstruction. It is concluded that chronic biliary obstruction and RI injection are prerequisites for the occurrence of lethal septicemia in the animals. The model might be suitable for the study of biliary sepsis in chronic biliary obstruction.