Investigation of bile ducts before laparoscopic cholecystectomy.
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BACKGROUND: Since the advent of laparoscopic cholecystectomy, there has been controversy about the investigation of the bile ducts and the management of common bile duct stones. Routine peroperative cholangiography (POC) in all cases has been recommended. We have adopted a policy of not performing routine POC, and the results of 700 cases are reported. METHODS: Since 1990, all patients have undergone preoperative ultrasound scan. We have performed selective preoperative endoscopic retrograde cholangiopancreatography (ERCP) because of a clinical history of jaundice and/or pancreatitis, abnormal liver function tests and ultrasound evidence of dilated bile ducts (N=78, 11.1%). The remaining 622 patients did not have a routine POC, but selective peroperative cholangiogram (POC) was performed only in 42 patients (6%) because of unsuccessful ERCP or mild alteration in the criteria for the presence of bile duct stones. The remaining 580 patients did not undergo POC. Careful dissection of Calot's triangle was performed in all cases to reduce the risk of bile duct injuries. RESULTS: The overall operative complications, postoperative morbidity and mortality was 1.71%, 2.14% and 0.43%, respectively. Bile duct injuries occurred in two patients (0.26%) and both were recognized during the operation and repaired. There was a single incidence of retained stone in this series of 700 cases (0.14%), which required postoperative ERCP. CONCLUSIONS: This policy of selective preoperative ERCP, and not routine peroperative cholangiogram, is cost effective and not associated with significant incidence of retained stones or bile duct injuries after laparoscopic cholecystectomy. (+info)
Acute carbon tetrachloride feeding induces damage of large but not small cholangiocytes from BDL rat liver.
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Bile duct damage and/or loss is limited to a range of duct sizes in cholangiopathies. We tested the hypothesis that CCl4 damages only large ducts. CCl4 or mineral oil was given to bile duct-ligated (BDL) rats, and 1, 2, and 7 days later small and large cholangiocytes were purified and evaluated for apoptosis, proliferation, and secretion. In situ, we measured apoptosis by morphometric and TUNEL analysis and the number of small and large ducts by morphometry. Two days after CCl4 administration, we found an increased number of small ducts and reduced number of large ducts. In vitro apoptosis was observed only in large cholangiocytes, and this was accompanied by loss of proliferation and secretion in large cholangiocytes and loss of choleretic effect of secretin. Small cholangiocytes de novo express the secretin receptor gene and secretin-induced cAMP response. Consistent with damage of large ducts, we detected cytochrome P-4502E1 (which CCl4 converts to its radicals) only in large cholangiocytes. CCl4 induces selective apoptosis of large ducts associated with loss of large cholangiocyte proliferation and secretion. (+info)
Detection of Helicobacter DNA in bile from bile duct diseases.
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Several species of Helicobacter colonize the hepatobiliary tract of animals and cause hepatobiliary diseases. The aim of this study is to investigate Helicobacter found in the biliary tract diseases of humans. Thirty-two bile samples (15 from bile duct cancer, 6 from pancreatic head cancer, and 11 from intrahepatic duct stone) were obtained by percutaneous transhepatic biliary drainage. Polymerase chain reaction analysis using Helicobacter specific urease A gene and 16S rRNA primers, bile pH measurement, and Helicobacter culture were performed. Helicobacter DNA was detected in 37.5%, and 31.3% by PCR with ureA gene, and 16S rRNA, respectively. The bile pH was not related to the presence of Helicobacter. The cultures were not successful. In conclusion, Helicobacter can be detected in the bile of patients with bile duct diseases. The possibility of pathogenesis of biliary tract diseases in humans by these organisms will be further investigated. (+info)
Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients.
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BACKGROUND: Helical computed tomography performed after intravenous administration of a cholangiographic contrast material (HCT-cholangiography) may be useful for detecting bile duct stones in non-jaundiced patients. However, this method has never been compared with other non-invasive biliary imaging tests. AIMS: To compare prospectively HCT-cholangiography and endosonography (EUS) in a group of non-jaundiced patients with suspected bile duct stones. METHODS: Fifty two subjects underwent both HCT-cholangiography and EUS. Endoscopic retrograde cholangiography (ERCP), with or without instrumental bile duct exploration, served as a reference method, and was successful in all but two patients. RESULTS: Thirty four patients (68%) were found to have choledocholithiasis at ERCP. The sensitivity for HCT-cholangiography in stone detection was 85%, specificity 88%, and accuracy 86%. For EUS the sensitivity was 91%, specificity 100%, and accuracy 94%. The differences were not significant. No serious complications occurred with either method. CONCLUSIONS: HCT-cholangiography and EUS are safe and comparably accurate methods for detecting bile duct stones in non-jaundiced patients. (+info)
Clinical features and management of biliary ascariasis in a non-endemic area.
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Biliary ascariasis is common in certain geographical areas of the world. In India, it is common in the Kashmir valley and only stray cases have been reported from other parts of the country. Between January 1995 and May 1997, 14 patients with biliary ascariasis were seen at our centre, which is more than 1000 km from the Kashmir valley. The mean (+/- SD) age of the patients was 31.7 (+/- 6.1) years and all were females. None of them had been to a place known to be endemic for biliary ascariasis. Four patients presented with acute cholangitis, eight with acute abdominal pain and vomiting, and the remaining two were diagnosed incidentally during surgery for gallstone disease. Barring these two patients, ultrasound examination of the abdomen diagnosed the condition accurately. In 10 patients, a part of the worm was visible outside the papilla of Vater. The roundworm was caught in a Dormia basket and could be extracted in nine patients. In one patient the worm migrated inside the bile duct while it was being caught in a Dormia basket. In this and two other patients, in whom the worm had migrated completely inside the bile duct, worms were removed with the help of a Dormia basket after endoscopic sphincterotomy. There were no complications of endoscopic therapy. In the two patients in whom biliary ascariasis was detected during surgery, the worms were removed after choledocholithotomy. On a mean follow-up of 13.8 months, only one patient had a recurrence of biliary ascariasis. It is concluded that biliary ascariasis is not an uncommon disease and must be considered as a possibility in patients presenting with acute cholangitis and biliary pain even in a non-endemic area. Ultrasonography is an excellent diagnostic tool and endoscopic management is very effective and safe in the treatment of these patients. (+info)
Expression of CD44 on bile ducts in primary sclerosing cholangitis and primary biliary cirrhosis.
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AIM: To examine expression of CD44, a transmembrane glycoprotein involved in lymphocyte homing and activation, in inflammatory liver diseases. METHODS: Formalin fixed, paraffin embedded tissues were obtained from normal, uninvolved liver from patients undergoing partial hepatectomy for metastatic carcinoma (9) and transplant hepatectomy specimens from patients with primary biliary cirrhosis (12), primary sclerosing cholangitis (8), autoimmune hepatitis (3), hepatitis C (3), and secondary sclerosing cholangitis (1). Expression of CD44 (using antibodies to three core epitopes), HLA-DR, and lymphocyte phenotypic markers was studied by immunohistochemistry. RESULTS: CD44 expression was not detected in either hepatocytes or biliary epithelial cells in normal livers. In sections from all 27 transplant hepatectomy specimens, CD44 was positive in bile duct epithelial cells but not in hepatocytes. The proportion of CD44+ ducts was much higher in biliary disease than in chronic hepatitis. By contrast, expression of HLA-DR was detected in a relatively small percentage of bile ducts. Activated, memory phenotype CD4+ T lymphocytes were increased in the parenchyma of all diseased livers and an infiltrate of activated CD8+ cells within the biliary epithelium was evident in inflammatory biliary disease. CONCLUSIONS: CD44 appears to play an important role in the development of autoimmune biliary disease by promoting lymphoepithelial interactions, whereas HLA-DR may be involved in the subsequent progression of these conditions. (+info)
Radiologic findings of Mirizzi syndrome with emphasis on MRI.
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We have reported a case of Mirizzi syndrome preoperatively diagnosed using MR cholangiopancreatography. MRCP and T2-weighted image using a single-shot fast spin-echo sequence accurately depicted all components of Mirizzi syndrome, including impacted stone in the neck of the gallbladder compressing the common hepatic duct and wall-thickening of the gallbladder without any evidence of malignancy. The combination of MRCP and T2-weighted image can be counted on to replace conventional modalities of diagnosing Mirizzi syndrome without any loss of diagnostic accuracy. (+info)
Characterization and isolation of ductular cells coexpressing neural cell adhesion molecule and Bcl-2 from primary cholangiopathies and ductal plate malformations.
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It has recently been shown that reactive bile ductules display neuroendocrine features, including immunoreactivity for the neural cell adhesion molecule (NCAM). In this study we have compared the immunohistochemical expression of NCAM with that of HEA-125 (biliary specific) and LKM-1 (hepatocyte specific) and other markers relevant to morphogenesis (Bcl-2, EMA) and cell proliferation (Ki-67) in cryostat sections from different chronic liver diseases and from fetal livers at different gestational ages. In parallel, viable NCAM-positive ductular cells were purified from collagenase digests of cirrhotic livers by immunomagnetic separation and characterized by immunocytochemistry and transmission electron microscopy. We demonstrated that reactive ductules with atypical morphology coexpressed NCAM and Bcl-2 and were found mainly in congenital diseases associated with ductal plate malformation and in primary cholangiopathies. On the contrary, reactive ductules with typical morphology were negative for NCAM/Bcl-2 and positive for EMA. Reactive ductules coexpressing NCAM/Bcl-2 were negative for the proliferation marker Ki-67 and appeared to be directly connected with periportal hepatocytes. In fetal livers NCAM/Bcl-2 was transiently expressed during the early developmental stages of ductal plate (10-16 weeks) and started to disappear as the ductal plate began duplicating. NCAM-positive ductal plate cells were Ki-67 negative, becoming positive in duplicated segments. Thus the histogenesis of ductular reactive cells seems to recapitulate the early stages of biliary ontogenesis. In primary cholangiopathies and ductal plate malformations, these cells do not appear to maturate further, and thus abundant ductular structures coexist with vanishing mature ducts. These NCAM-positive ductular cells were immunopurified from patients with chronic cholestatic liver diseases and showed ultrastructural features consistent with a less differentiated phenotype than mature cholangiocytes. These isolated cells represent a useful model for in vitro studies. (+info)