Chronic cough due to bronchobiliary fistula.
Bronchobiliary fistula is a rare cause of chronic cough. Here we describe a 70-year-old woman complaining of chronic cough and copious dark-yellow watery sputum. The presence of air in the biliary tract in the lower cuts of a computerized tomography scan of the chest and positive bile in the sputum led to the suspicion of bronchobiliary fistula. The diagnosis was confirmed by percutaneous transhepatic cholangiography. Drainage of the intrahepatic biliary tract resulted in complete resolution of her symptoms. (+info)
Roux-en-Y hepaticojejunostomy: a reappraisal of its indications and results.
A critical evaluation is made of 131 patients submitted to choledocho or hepaticojejunostomy. The main indications for hepaticojejunostomy were iatrogenic strictures of CBD (60 patients), and choledocholithiasis with markedly dilated duct (41 patients). The overall mortality rate was 4% representing principally renal hepatic failure, bile peritonitis and bleeding. The complications following hepaticojejunostomy included only in one case biliary fistula which required reoperation. The long-term results of 80 patients available for a followup study were as follows: 63 patients (78.7%) were symptom-free at 2-13 years followup; 8 patients had brief episodes of cholangitis which responded to antibiotic and corticosteroid treatment; 9 patients required reoperation for stricture of anastomosis. These overall results are a strong argument for hepaticojejunostomy which, compared with choledochoduodenostomy, avoids the hazards of the so-called sump syndrome and of the reflux of enteric contents in the CBD. An increased incidence of peptic ulcer disease in the patients submitted to hepaticojejunostomy was not observed. In very high strictures and in reinterventions anastomosis between left hepatic duct and Roux-en-Y jejunal limb was carried out. The results achieved with this technique, which was performed in 26 patients, were about the same following hepaticojejunostomy. (+info)
Genetic factors at the enterocyte level account for variations in intestinal cholesterol absorption efficiency among inbred strains of mice.
Interindividual and interstrain variations in cholesterol absorption efficiency occur in humans and animals. We investigated physiological biliary and small intestinal factors that might determine variations in cholesterol absorption efficiency among inbred mouse strains. We found that there were significant differences in cholesterol absorption efficiency measured by plasma, fecal, and lymphatic methods: <25% in AKR/J, C3H/J, and A/J strains; 25-30% in SJL/J, DBA/2J, BALB/cJ, SWR/J, and SM/J strains; and 31-40% in C57L/J, C57BL/6J, FVB/J, and 129/SvJ strains. In (AKRxC57L)F1 mice, the cholesterol absorption efficiency (31 +/- 6%) mimicked that of the C57L parent (37 +/- 5%) and was significantly higher than in AKR mice (24 +/- 4%). Although biliary bile salt compositions and small intestinal transit times were similar, C57L mice displayed significantly greater bile salt secretion rates and pool sizes than AKR mice. In examining lymphatic cholesterol transport in the setting of a chronic biliary fistula, C57L mice displayed significantly higher cholesterol absorption rates compared with AKR mice. Because biliary and intestinal transit factors were accounted for, we conclude that genetic variations at the enterocyte level determine differences in murine cholesterol absorption efficiency, with high cholesterol absorption likely to be a dominant trait. This study provides baseline information for identifying candidate genes that regulate intestinal cholesterol absorption at the cellular level. (+info)
Biliary-bronchial fistula demonstrated by endoscopic retrograde cholangiography.
Endoscopic retrograde cholangiography is valuable in the evaluation of biliary tract disorders. A 50-year-old Italian woman developed biloptysis 1 year after cholecystectomy because of intrabiliary rupture of a hydatid cyst with secondary infection, which resulted in intrathoracic rupture and communication with the bronchial tree. Endoscopic retrograde cholangiography showed the cause and pathway of the fistulous tract by outlining the biliary tree, abscess cavity and communication with the right upper lobe bronchus. This technique appears to be well suited to the investigation of patients with biliary-bronchial fistula. (+info)
External biliary fistula.
External biliary fistulas, once common, are now rare: before the present report of 4 cases only 27 cases have been reported in the English literature since 1900. Review of the records of four patients with external biliary fistula confirmed its occurrence in patients over 50 years of age and the variable site for operning of the fistulous tract. Cholecystectomy provided successful treatment in three of the four patients but the fourth was too ill to undergo an operation; in general, definitive treatment is cholecystectomy, together with excision of the fistulous tract if this takes a direct path through the abdominal wall from the gallbladder, or curettage if the course is devious. (+info)
Percutaneous evacuation (PEVAC) of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material: first results of a modified PAIR method.
BACKGROUND: Surgery is the treatment of choice in echinococcal cysts with cystobiliary fistulas. PAIR (puncture, aspiration, injection, and reaspiration of scolecidals) is contraindicated in these cases. AIM: To evaluate a modified PAIR method for percutaneous treatment of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material. PATIENTS: Twelve patients were treated: 10 patients with multivesicular cysts which contained non-drainable material and were complicated by spontaneous intrabiliary rupture, secondary cystobiliary fistulas, cyst infection, or obstructed portal or hepatic veins; and two patients with large univesicular cysts and a ruptured laminated membrane, one obstructing the portal and hepatic veins and one a suspected cystobiliary fistula. METHODS: The methods used, termed PEVAC (percutaneous evacuation of cyst content), involved the following steps: ultrasound guided cyst puncture and aspiration of cyst fluid to release intracystic pressure and thereby to avoid leakage; insertion of a large bore catheter; aspiration and evacuation of daughter cysts and endocyst by injection and reaspiration of isotonic saline; cystography; injection of scolecidals only if no cystobiliary fistula was present; external drainage of cystobiliary fistulas combined with endoprosthesis or sphincterotomy; catheter removal after complete cyst collapse and closure of the cystobiliary fistula. RESULTS: In all 12 patients initial cyst size was 13.1 (6-20) cm (mean (range)). At follow up 17.9 (4-30) months after PEVAC, seven cysts had disappeared and five cysts had decreased to 2.4 (1-4) cm (p=0.002). In eight patients with multivesicular cysts, a cystobiliary fistula, and infection, cyst size was 12.5 (6-20) cm, catheter time 72.3 (28-128) days, and hospital stay 38.1 (20-55) days. At 17.3 (4-28) months of follow up, six cysts had disappeared and in two cysts residual size was 1 and 2.9 cm, respectively (p=0.012). In four patients without a cystobiliary fistula, cyst size was 14.4 (12.7-16) cm, catheter time 8.8 (3-13) days, and hospital stay 11.5 (8-14) days. At 19.3 (9-30) months of follow up, one cyst had disappeared and three cysts were 85 (69-94)% smaller (2.2 (1-4) cm) (p=0.068). CONCLUSION: PEVAC is a safe and effective method for percutaneous treatment of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material. (+info)
Regulation of hepatic connexins in cholestasis: possible involvement of Kupffer cells and inflammatory mediators.
Hepatocyte gap junction proteins, connexins (Cxs) 26 and 32, are downregulated during obstructive cholestasis (OC) and lipopolysaccharide hepatocellular cholestasis (LPS-HC). We investigated rat hepatic Cxs during ethynylestradiol hepatocellular cholestasis (EE-HC) and choledochocaval fistula (CCF) and compared them with OC and LPS-HC. Levels (immunoblotting) and cellular distribution (immunofluorescence) of Cx26, -32, and -43, as well as macrophage infiltration, were studied in livers of rats under each condition. Cx26 and -32 were reduced in LPS-HC, OC, and CCF. However, in EE-HC, Cx26 did not change and Cx32 was increased. Prominent inflammation occurred in LPS-HC, OC, and CCF, which was associated with increased levels of Cx43 in LPS-HC and OC but not CCF. No inflammation nor changes in Cx43 levels occurred during EE-HC. In cultured hepatocytes, dye coupling was reduced by tumor necrosis factor-alpha and interleukins-1beta and -6, whereas reduction induced by LPS required coculture with Kupffer cells. Thus hepatocyte gap junctions are downregulated in forms of cholestasis associated with inflammation, and reduced intercellular communication might be induced in part by proinflammatory mediators. (+info)
Sirolimus/cyclosporine/tacrolimus interactions on bile flow and biliary excretion of immunosuppressants in a subchronic bile fistula rat model.
The new immunosuppressive agent sirolimus generally is combined in transplant patients with cyclosporine and tacrolimus which both exhibit cholestatic effects. Nothing is known about possible cholestatic effects of these combinations which might be important for biliary excretion of endogenous compounds as well as of immunosuppressants. Rats were daily treated with sirolimus (1 mg kg(-1) p.o.), cyclosporine (10 mg kg(-1) i.p.), tacrolimus (1 mg kg(-1) i.p.), or a combination of sirolimus with cyclosporine or tacrolimus. After 14 days a bile fistula was installed to investigate the effects of the immunosuppressants and their combinations on bile flow and on biliary excretion of bile salts, cholesterol, and immunosuppressants. Cyclosporine as well as tacrolimus reduced bile flow (-22%; -18%), biliary excretion of bile salts (-15%;-36%) and cholesterol (-15%; -47%). Sirolimus decreased bile flow by 10%, but had no effect on cholesterol or bile salt excretion. Combination of sirolimus/cyclosporine decreased bile flow and biliary bile salt excretion to the same extent as cyclosporine alone, but led to a 2 fold increase of biliary cholesterol excretion. Combination of sirolimus/tacrolimus reduced bile flow only by 7.5% and did not change biliary bile salt and cholesterol excretion. Sirolimus enhanced blood concentrations of cyclosporine (+40%) and tacrolimus (+57%). Sirolimus blood concentration was increased by cyclosporine (+400%), but was not affected by tacrolimus. We conclude that a combination of sirolimus/tacrolimus could be the better alternative to the cotreatment of sirolimus/cyclosporine in cholestatic patients and in those facing difficulties in reaching therapeutic ranges of sirolimus blood concentration. (+info)