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La colangiopatía portal hace referencia a anomalías colangiográficas que se producen en pacientes con cavernomatosis portal, siendo progresiva, cursando con enfermedad biliar sintomática y anomalías graves de las vías biliares. Y, representa una complicación infrecuente de la hipertensión portal. Se describe el caso de un hombre de 53 años, con historia de larga data de hipertensión portal nocirrótica y cavernomatosis portal, quien presentó un episodio de enfermedad biliar obstructiva sintomática, y en estudios se documentó tejido fibrótico de extensión periportal ascendente con compresión extrínseca del colédoco distal y dilatación de la vía biliar extra e intrahepática. Por lo que se procedió a colangiopancreatografía retrógrada endoscópica, realizándose tratamiento paliativo, con papilotomía pequeña y colocación de endoprótesis biliar plástica, siendo exitoso por ausencia de complicaciones procedimentales, y mejoría clínica y parámetros bioquímicos. Finalmente, recibiendo de alta con indicación de seguimiento prioritario para recambios periódicos de endoprótesis biliares, y valoración por hepatología. La colangiopatía portal es una entidad rara que debe sospecharse en sujetos con hipertensión portal de origen no-cirrótico, con hallazgos imagenológicos de estenosis, angulaciones o dilataciones segmentarias, su tratamiento debe ser individualizado, y la terapia endoscópica es de elección en enfermedad biliar sintomática.
Portal cholangiopathy refers to cholangiographic abnormalities occurring in patients with portal cavernomatosis, being progressive, presenting with symptomatic biliary disease and severe biliary tract abnormalities. And, it represents an infrequent complication of portal hypertension. We describe the case of a 53-year-old man with a long history of non-cirrhotic portal hypertension and portal cavernomatosis, who presented an episode of symptomatic obstructive biliary disease, and studies documented fibrotic tissue of ascending periportal extension with extrinsic compression of the distal common bile duct and dilatation of the extra and intrahepatic biliary tract. Therefore, endoscopic retrograde cholangiopancreatography was performed, and palliative treatment with small papillotomy and placement of a plastic biliary endoprosthesis was successful due to the absence of procedural complications, and clinical improvement and biochemical parameters. Finally, the patient was discharged with indication of priority follow-up for periodic replacement of biliary stents, and evaluation by hepatology. Portal cholangiopathy is a rare entity that should be suspected in subjects with portal hypertension of non-cirrhotic origin, with imaging findings of stenosis, angulations or segmental dilatations, its treatment should be individualized, and endoscopic therapy is of choice in symptomatic biliary disease.
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Malignant obstructive jaundice is caused by direct invasion or compression of the biliary tract by malignant tumors of the bile duct, pancreas and other systems. Patients are often accompanied by symptoms such as malnutrition, low immune function, and organ damage. The treatments of active preoperative biliary drainage and reasonable reinfusion combined with enteral nutrition can help improve the safety of patients during the perioperative period, reduce postoperative complications, and improve the life quality of patients. This article reviewed the research progress of preoperative biliary drainage, bile recycling methods and precautions in patients with malignant obstructive jaundice, aiming to provide reference for clinical diagnosis and treatment practice.
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Objective:To investigate the efficacy of endoscopic retrograde cholangiopancreatography in the treatment of Child-Pugh C cirrhosis complicated by obstructive jaundice and its effects on liver function and infection indexes.Methods:The clinical data of 86 patients with Child-Pugh C cirrhosis complicated by obstructive jaundice who received treatment in the Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, from June 2017 to June 2022 were retrospectively analyzed. These patients were divided into an observation group ( n = 56) and a control group ( n = 30) according to different treatment methods. Patients in the observation group underwent endoscopic retrograde cholangiopancreatography and those in the control group received conservative drug treatment. After 14 days of treatment, clinical efficacy was compared between the two groups. The changes in liver function [alanine aminotransferase (ALT), aspartate aminotransferase (AST), glutamyl transpeptide (GGT)] and infection indicators [white blood cell count (WBC), procalcitonin (PCT), and C-reactive protein (CRP)] were compared between the two groups before and after treatment. The incidence of postoperative complications was compared between the two groups. At 6 months after treatment, the prognosis was compared between the two groups. Results:The total response rate in the observation group was 98.21% (55/56), which was significantly higher than 60.00% (18/30) in the control group ( Z = 23.43, P < 0.001). Before treatment, serum ALT, AST, GGT levels in the control group were (294.53 ± 45.19) U/L, (286.62 ± 17.15) U/L, and (304.53 ± 12.34) U/L, respectively, and they were (96.25 ± 16.7) U/L, (113.25 ± 8.56) U/L, (122.25 ± 9.24) U/L after 14 days of treatment. Before treatment, serum ALT, AST, and GGT levels in the observation group were (352.36 ± 70.23) U/L, (303.31 ± 12.12) U/L, and (368.36 ± 10.23) U/L, respectively, and they were (108.65 ± 12.38) U/L, (95.65 ± 6.54) U/L, and (85.66 ± 7.28) U/L, respectively, after 14 days of treatment. After treatment, serum ALT, AST, and GGT levels in each group were significantly decreased compared with those before treatment (observation group t = 22.54, 49.54, 64.76; control group t = 25.57, 112.83, 168.48, all P < 0.05). After treatment, the amplitude of decrease in serum ALT, AST, and GGT levels in the observation group were significantly greater than those in the control group ( t = 2.27, 3.18, 4.61, all P < 0.05). After treatment, PCT, CRP, and WBC in each group were significantly decreased compared with those before treatment (observation group: t = 11.68, 11.46, 5.42, control group: t = 20.39, 18.69, 19.02, all P < 0.05). After treatment, the amplitude of decrease in serum PCT, CRP, and WBC in the observation group were significantly greater than those in the control group ( t = 5.14, 1.67, and 2.11, all P < 0.05). Within 14 days after treatment, there were two cases of acute pancreatitis, one case of hyperamylasemia, and one case of transient biliary bleeding in the observation group. There was one case of acute pancreatitis in the control group. The incidence of complications in the observation group was slightly, but not significantly, higher than that in the control group ( P > 0.05). After treatment, 12 patients (40.00%) in the control group experienced worsening jaundice, and additional endoscopic retrograde cholangiopancreatography salvage treatment was given. After treatment, total bilirubin level decreased by > 50%, reaching the standard of significant efficacy. At 6 months after treatment, stent obstruction occurred in two patients, which was effectively treated by replacement. There were no deaths in each group during the follow-up period. Conclusion:Implantation of a nasobiliary duct or a biliary duct stent during endoscopic retrograde cholangiopancreatography is more effective at treating yelloxemia in patients with Child-Pugh C cirrhosis complicated by obstructive jaundice than medication. The former method can effectively relieve obstructive jaundice, smooth drainage, improve liver function, reduce infection, and be relatively safe.
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Objective To investigate the effect of Yinchenhao decoction on renal oxidative stress injury in rats with obstructive jaundice and its association with the regulation of the expression of nuclear factor erythroid 2-related factor 2 (Nrf2) and nuclear translocation. Methods A total of 32 male Sprague-Dawley rats were randomly divided into sham-operation group (S group), model group (O group), low-dose Yinchenhao decoction group (LY group), and high-dose Yinchenhao decoction group (HY group), with 8 rats in each group. For the rats in the S group, the upper common bile duct was isolated without ligation, and for those in the other groups, double ligation of the middle and upper 1/3 of the common bile duct was performed to establish a model of obstructive jaundice. After 7 days, the rats in the LY group and the HY group were given Yinchenhao decoction by gavage at a dose of 6.3 and 18.9 mL/kg, respectively, while those in the S and O groups were given an equal volume of distilled water by gavage every day for 7 consecutive days, and the rats were treated on day 14. ELISA was used to measure the serum levels of total bilirubin (TBil), direct bilirubin (DBil), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), blood urea nitrogen (BUN), and creatinine (Cr); spectrophotometry was used to measure the activity of the oxidative stress factors superoxide dismutase (SOD) and malondialdehyde (MDA) in renal tissue; quantitative real- time PCR and Western blotting were used to measure the mRNA and protein expression levels of Nrf2, Kelch-like ECH-associated protein 1 (Keap1), and NAD(P)H quinone dehydrogenase 1 (NQO1) in renal tissue; immunohistochemistry was used to measure observe the nuclear translocation of Nrf2 protein in renal tissue. A one-way analysis of variance was used for comparison of continuous data between multiple groups, and the least significant difference t -test was used for further pairwise comparison within groups. Results Compared with the S group, the O group had significant increases in the levels of TBil, DBil, ALT、GGT, BUN, and Cr, a significant reduction in the activity of SOD, and a significant increase in the level of MDA (all P 0.05). Compared with the S group, the O group had a significant reduction in the positive rate of Nrf2 in cell nucleus in renal tissue ( P < 0.05), and compared with the O group, the LY group and the HY group had a significant increase in the positive rate of Nrf2 in cell nucleus ( P < 0.05). Conclusion Yinchenhao decoction can effectively alleviate renal injury caused by obstructive jaundice, possibly by upregulating the protein expression of Nrf2 in renal tissue and regulating the nuclear translocation of Nrf2 protein, so as to mediate the protein expression of downstream NQO1, regulate oxidative stress response caused by obstructive jaundice, and thereby alleviate renal injury in rats.
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Objective:To investigate the risk factor analysis and model prediction of bleeding after endoscopic retrograde cholangiopancreatography in patients with malignant obstructive jaundice (MOJ).Methods:A retrospective analysis was performed on 302 patients with MOJ treated with ERCP who were treated in the No. 363 Hospital Affiliated to Southwest Medical University from January 2015 to June 2021. The general clinical data of the patients were collected, and the biochemical indicators of the pancreatic and bile ducts were detected. The patients were followed up after discharge, and the patients were divided into a bleeding group ( n=47) and a control group ( n=255) according to whether the follow-up patients were bleeding after ERCP. Compared the general and clinical data of the two groups of patients, including age, gender, platelet count, presence of bile duct stones, acute cholangitis, acute pancreatitis, number of stones, intraoperative bleeding, pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and pre-surgical incision. The measurement data that obey the normal distribution were represented by the mean±standard deviation ( ± s), and the two independent sample t test was used for the comparison between groups; the data that do not conform to the normal distribution were represented by M ( Q1, Q3), and the comparison between groups was used Mann-Whitney U test. The comparison of enumeration data between groups adopted chi-square test. Logistic multivariate regression was used to analyze the independent risk factors of postoperative bleeding after ERCP, and a nomogram prediction model was established and verified according to the independent risk factors of postoperative bleeding. Results:The two groups of patients were compared in age, gender, platelet count, bile duct stones, acute cholangitis, acute pancreatitis, the number of stones, intraoperative bleeding and other aspects, the difference was not statistically significant ( P>0.05). The percentages of pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and surgical pre-incision in the bleeding group were 12.77%, 17.02%, 19.15%, 51.06%, 59.57%, and 14.89%, respectively. , the percentages of the control group were 3.92%, 5.10%, 9.02%, 19.22%, 17.65%, and 5.88%, and the difference was statistically significant between the two groups ( P<0.05). Taking postoperative bleeding as the dependent variable, and using the indicators with statistical differences in univariate analysis as independent variables, multivariate Logistic regression analysis showed that the patient had pancreatic cancer ( OR=1.838, 95% CI: 1.524-4.613, P=0.041), cholangiocarcinoma ( OR=2.548, 95% CI: 1.870-5.116, P=0.015), stone incarceration ( OR=3.078, 95% CI: 2.374-6.012, P<0.001), duodenum Intestinal papillary diverticula ( OR=1.140, 95% CI: 1.045-1.628, P<0.001), surgical pre-incision ( OR=1.640, 95% CI: 1.321-1.928, P<0.001) were associated with postoperative bleeding in MOJ patients after ERCP independent risk factors. The predictive ability of duodenal papillary diverticulum was the highest; the predictive ability of stone incarceration and cholangiocarcinoma was the second, and there was no significant difference between them; the predictive ability of pancreatic cancer, stone diameter, and pre-incision on bleeding after ERCP in MOJ patients smaller. Pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and pre-incision scores were 42, 63, 28, 65, 76, and 34 points respectively, and the total score was 308 points corresponding to the nomogram model. The predictive power of the nomogram was 61.6%, and overall, the nomogram had good predictive performance. Harrell concordance index analysis and ROC curve were used to evaluate the model discrimination, the C-index calculation result was 0.826 (95% CI: 0.771-0.847), the ROC curve AUC was 0.843 (95% CI: 0.801-0.884), and the ROC prediction The value and the calculation result of C-index are relatively close. The model discrimination is applied in this study and has a certain prediction effect. The nomogram model in the Calibration curve predicted the probability of postoperative bleeding after ERCP in MOJ patients with high consistency with the actual probability. Conclusion:ERCP is safe and feasible for most patients with MOJ, but for patients with pancreatic cancer, bile duct cancer, large stone diameter, stone incarceration, and duodenal papillary diverticulum, it should be performed with caution, and preoperative incision should be avoided, to reduce the risk of postoperative bleeding. In addition, the nomogram model has a strong predictive ability in predicting bleeding after ERCP in patients with MOJ, which is worthy of reference in clinical research.
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Objective:To investigate the effect of autophagy on liver injury with obstructive jaundice in Sprague-Dawley (SD) rats and its underlying mechanism.Methods:Thirty-five healthy male SD rats, SPF grade, aged 6-8 weeks, weighting 200-300 g, were divided into 5 groups with 7 rats in each group, including sham group (simple free common bile duct, without ligation, intraperitoneal injection of normal saline), obstructive jaundice (OJ) group (established by common bile duct ligation, intraperitoneal injection of normal saline), OJ group with 3-MA, OJ group with Rapamycin, and OJ group with 3-MA and VX-765. Morphological changes in liver tissues were analyzed with HE staining. Expression of autophagy-related protein Atg5 was detected by immunohistochemistry staining. Liver function was analyzed by automatic biochemical instrument and the level of serum interleukin (IL)-18 was detected using ELISA assay. Protein levels of autophagy related-proteins and endoplasmic reticulum stressed (ERs)-related apoptosis proteins were detected by Western Blot.Results:The relative expression of autophagy related protein Atg5 in OJ group was significantly higher than that in sham group [(5.0±1.0) vs. (2.8±1.3), t=-3.00, P<0.05]. Compared with sham group, the activity of autophagy was enhanced and the protein levels of Caspase-1/p-65 and IL-18 were significantly increased in OJ group. At the same time, apoptosis was induced by activating ERs. In OJ group, the autophagy inducer 3-MA improved the expression levels of Caspase-1/p-65 and IL-18, and aggravate liver injury. While after applying the autophagy agonist Rapamycin in OJ rat models, the expression of Caspase-1/p-65 and IL-18 was repressed and liver damage was also reduced. In addition, in rat OJ groups with 3-MA, inhibition of Caspase-1 by VX-765 could down regulate the expression of Caspase-1/p-65 and IL-18, and protect against liver injury. Conclusions:Both ERs related apoptosis and autophagy were activated after ligation of common bile duct. Besides, activation of autophagy could reduce OJ-induced liver injury in SD rats by inhibiting the Caspase-1/p-65 inflammatory pathway.
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Objective:To explore the risk factors and preventive strategies of pancreatitis after percutaneous transhepatic biliary drainage (PTBD) in patients with pancreatic cancer and obstructive jaundice.Methods:A total of 241 patients were retrospectively analyzed from May 2001 to October 2014 in Tianjin Medical University Cancer Institute and Hospital. The possibly correlated 9 factors were analyzed, including gender, age, hemoglobin level, total bilirubin level, degree of pancreatic duct dilatation, degree of pancreatic atrophy, degree of biliary stenosis, the pancreatic duct visualization, and drainage mode.Results:Univariate analysis suggested that pancreatic duct dilatation, pancreatic atrophy, visualized pancreatic duct and drainage mode were associated with the incidence of pancreatitis after PTBD ( P<0.05). Logistic regression analysis showed that visualization of pancreatic duct ( OR=6.33) was a risk factor for pancreatitis, while pancreatic duct dilatation ( OR=0.14), pancreatic atrophy ( OR=0.12) and external drainage ( OR=0.11) were protective factors for pancreatitis. Conclusion:In pateints with pancreatic cancer and obstructive jaundice, pancreatic duct dilatation and pancreatic atrophy predict low risk of pancreatitis after PTBD,while intraoperative pancreatic duct visualization and internal or external drainage may increase the incidence of postoperative pancreatitis.
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Objective:To compare the clinical effect of three indwelling methods of plastic biliary stent on relieving obstructive jaundice caused by unresectable hilar cholangiocarcinoma.Methods:A retrospective study was performed on data of 61 patients with obstructive jaundice caused by unresectable hilar cholangiocarcinoma from April 2014 to December 2020 in Cancer Hospital, Chinese Academy of Medical Sciences. Plastic biliary stent placement was used to relieve jaundice, including 18 cases of intragastric indwelling at the end of biliary stent, 31 cases of duodenal papilla indwelling at the end of biliary stent, and 12 cases of horizontal portion of duodenum indwelling at the end of biliary stent. Incidence of fever within 2 weeks, perioperative mortality, 90-day obstruction rate, and median stent patency period were followed up and the results were analyzed.Results:The incidence of fever within 2 weeks of the three groups were significantly different [66.7% (12/18), 58.1% (18/31) and 16.7% (2/12), χ2=7.30, P=0.026]. There were no statistically differences in the perioperative mortality [0 (0/16), 3.2% (1/31) and 0 (0/10), χ2=1.09, P=1.000], 90-day obstruction rate [52.9% (9/17), 48.3% (14/29) and 40.0% (4/10), χ2=1.91, P=0.589], or median stent patency period (66.0 d, 91.5 d and 94.0 d, Z=4.96, P=0.084) among three groups. Conclusion:Patients with biliary plastic stents with ends placed at the horizontal portion of the duodenum show lower incidence of fever within two weeks after implantation, and similar median stent patency period, 90-day obstruction rate and perioperative mortality compared with intragastric indwelling and duodenal papilla indwelling groups. Therefore, biliary plastic stents with ends placed at the horizontal portion of the duodenum should be recommended as the preferred procedure.
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Objective:To explore the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) biliary stent implantation in patients with unresectable malignant biliary stricture (MBS) and the influencing factors of overall survival.Methods:The clinical data of 346 patients who underwent ERCP biliary stent implantation due to MBS from May 2013 to October 2016 in Xijing Digestive Disease Hospital of Air Force Military Medical University, Shanxi Bethune Hospital and Mengchao Hepatobiliary Hospital of Fujian Medical University were retrospectively analyzed, and the efficacy, complications and risk factors affecting overall survival were also analyzed.Results:After ERCP biliary stent implantation, the levels of total bilirubin, γ-glutamyl transpeptidase, alkaline phosphatase and alanine aminotransferase were lower than those before surgery (all P < 0.01). The incidence of infection after operation was 14.7% (51/346), and the incidence of biliary infection was 13.0% (45/346). The incidence of post-ERCP pancreatitis (PEP) was 4.6% (16/346). The median survival time after ERCP was 131.0 d (70.3 d, 246.5 d). Multivariate Cox regression analysis showed that the independent risk factors affecting the overall survival patients included the hilar bile duct stenosis ( HR = 1.85, 95% CI 1.44-2.38, P < 0.01), preoperative bilirubin level exceeding the upper limit of normal level by 5 times ( HR = 1.75, 95% CI 1.30-2.36, P < 0.01), carbohydrate antigen 199 level exceeding the upper limit of normal level by 10 times ( HR = 1.27, 95% CI 1.00-1.61, P = 0.050), vascular and organ metastasis ( HR = 1.32, 95% CI 1.04-1.69, P = 0.023), and the poor jaundice decreasing level ( HR = 1.37, 95% CI 1.02-1.85, P = 0.037) . Conclusions:The ERCP biliary stent implantation is a safe and effective therapy for MBS. ERCP biliary stent implantation MBS patients with hilar bile duct stenosis, preoperative bilirubin levels more than 5 times of the upper limit of normal level, carbohydrate antigen 199 levels more than 10 times of the upper limit of normal level, vascular and organ metastasis, and poor jaundice decreasing level may have poor overall survival.
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Objective:To systematically evaluate the clinical effect of biliary stent combined with intra-biliary radiofrequency ablation and stent alone in the treatment of malignant obstructive jaundice.Methods:The PubMed, Cochrane library, Embase, HowNet, Wanfang, Weipu were systematically searched, the search time was up to February 2021. To collect and compare the clinical efficacy studies of combined intra-biliary radiofrequency ablation in the treatment of patients with malignant obstructive jaundice before biliary stent placement. After literature screening, data extraction and quality assessment conducted by two independent reviewers. Meta-analysis was performed with the patients' 1-year survival rate, 6-month patency rate after biliary stent operation, and comparative changes in postoperative complications as the main outcome indicators.Results:Finally, 9 studies were included, comprising 2 randomized controlled studies (RCT) and 7 retrospective studies, involving a total of 443 patients, with 211 cases in the biliary stent combined with intra-biliary radiofrequency ablation group and 232 cases in the stent alone group. The results of meta-analysis showed that in two joint groups compared with the stent alone group, in overall analysis, the rate of re-obstruction of the biliary tract decreased 6 months after stenting ( OR=0.24, 95% CI: 0.13-0.42) and 1-year survival rate increased ( OR=3.79, 95% CI: 2.08-6.90), the differences are statistically significant ( P<0.001), there was no statistical difference in the complications ( P=0.13). In ERCP group, the rate of re-obstruction of the biliary tract decreased 6 months after stenting ( OR=0.21, 95% CI: 0.08-0.55), and the 1-year survival rate significant increase ( OR=3.63, 95% CI: 1.76-7.48), the differences are statistically significant ( P<0.01). In PTCD group, the rate of re-obstruction of the biliary tract decreased 6 months after stenting ( OR=0.25, 95% CI: 0.12-0.51), and the 1-year survival rate significant increase ( OR=4.13, 95% CI: 1.42-12.03), the differences are statistically significant ( P<0.01). Conclusion:Compared with the stent-only group, the combined group is safe and effective in treating malignant obstructive jaundice.