Cholangiocarcinoma: Diagnosis and Management.

Cholangiocarcinoma is a highly lethal biliary epithelial tumor that is rare in the general population but has increased rates in patients with primary sclerosing cholangitis (PSC). It is heterogenous, and management varies by location. No effective prevention exists, and screening is likely only feasible in PSC. Patients often present in an advanced state with jaundice, weight loss, and cholestatic liver enzymes. Diagnosis requires imaging with magnetic resonance cholangiopancreatography, laboratory testing, and endoscopic retrograde cholangiopancreatography. Potentially curative options include resection and liver transplant with neoadjuvant or adjuvant chemoradiation. Chemotherapy, radiation, and locoregional therapy provide some survival benefit in unresectable disease.

Oral Litholysis in Patients with Chronic Calcific Pancreatitis Unresponsive to or Ineligible for Extracorporeal Shock Wave Lithotripsy and Endoscopic Therapy.

BACKGROUND/AIMS: Our study aimed to evaluate the effect of oral litholysis in patients with chronic calcific pancreatitis (CCP) unresponsive to or ineligible for extracorporeal shock wave lithotripsy (ESWL) and endoscopic therapy. METHODS: Trimethadione, an antiepileptic agent, was administered orally at a dose of 0.6-0.9 g/day to 15 patients with this condition. Treatment outcome was evaluated by assessment of dissolution of the pancreatic stones on plain X-ray films and computed tomography scans of the upper abdomen. Plasma glucose, hemoglobin A1c, and body mass index (BMI) were also monitored throughout the therapy. RESULTS: Litholysis was observed in 13 out of 15 patients (86.7%) and was definite in 10 and partial in 3. Six patients had pancreatitis attacks during the therapy; 5 of whom showed definite litholysis and had only 1 mild attack. Of the 11 patients with normal or impaired glucose tolerance at baseline, none developed diabetes mellitus and all showed litholysis. BMI significantly increased in patients whose pancreatic stones dissolved. There was no vital organ impairment by trimethadione. CONCLUSION: Oral litholysis using trimethadione may represent a noninvasive and effective complementary treatment in patients with CCP unresponsive to or ineligible for ESWL and endoscopic therapy.

Use of Omega-3 Polyunsaturated Fatty Acids to Treat Inspissated Bile Syndrome: A Case Report / 대한소아소화기영양학회지

Inspissated bile syndrome (IBS) is a rare condition in which thick intraluminal bile, including bile plugs, sludge, or stones, blocks the extrahepatic bile ducts in an infant. A 5-week-old female infant was admitted for evaluation of jaundice and acholic stool. Diagnostic tests, including ultrasound sonography, magnetic resonance cholangiopancreatography, and a hepatobiliary scan, were not conclusive. Although the diagnosis was unclear, the clinical and laboratory findings improved gradually on administration of urodeoxycholic acid and lipid emulsion containing omega-3 polyunsaturated fatty acids (PUFAs) for 3 weeks. However, a liver biopsy was suggestive of biliary atresia. This finding forced us to perform intraoperative cholangiography, which revealed a patent common bile duct with impacted thick bile. We performed normal saline irrigation and the symptom was improved, the final diagnosis was IBS. Thus, we herein report that IBS can be treated with omega-3 PUFAs as an alternative to surgical intervention.

Sclerosing cholangitis secondary to bleomycin-iodinated embolization for liver hemangioma.

Sclerosing cholangitis (SC) is a rarely reported morbidity secondary to transcatheter arterial chemoembolization (TACE) with bleomycin-iodinated oil (BIO) for liver cavernous hemangioma (LCH). This report retrospectively evaluated the diagnostic and therapeutic course of a patient with LDH who presented obstructive jaundice 6 years after TACE with BIO. Preoperative imaging identified a suspected malignant biliary stricture located at the convergence of the left and right hepatic ducts. Operative exploration demonstrated a full-thickness sclerosis of the hilar bile duct with right hepatic duct stricture and right lobe atrophy. Radical hepatic hilar resection with right-side hemihepatectomy and Roux-en-Y hepaticojejunostomy was performed because hilar cancer could not be excluded on frozen biopsy. Pathological results showed chronic pyogenic inflammation of the common and right hepatic ducts with SC in the portal area. Secondary SC is a long-term complication that may occur in LCH patients after TACE with BIO and must be differentiated from hilar malignancy. Hepatic duct plasty is a definitive but technically challenging treatment modality for secondary SC.

Evaluation of date syrup as an oral negative contrast agent for MRCP.

OBJECTIVE: The purpose of this study was to compare the in vitro effects of date syrup with those of other contrast agents by qualitative and quantitative analysis and in vivo evaluation of the use of date syrup to improve the quality of MRCP images. MATERIALS AND METHODS: Phantoms containing date syrup, ferumoxsil, pineapple juice, and water were imaged by 1.5-T MRI with T2-weighted and MRCP sequences, and signal-to-noise ratios were calculated. Biochemical analysis of date syrup was performed to find the nature of iron in it, and the iron content was quantified by energy-dispersive x-ray spectroscopy. Sixty patients underwent MRCP before and 30 minutes after ingestion of 100 mL of date syrup. Unenhanced and contrast-enhanced images were scored for gastrointestinal tract signal suppression and visualization of various pancreaticobiliary structures. RESULTS: In vitro evaluation showed that images obtained with date syrup had a signal-to-noise ratio comparable to that of images obtained with ferumoxsil in T2-weighted and MRCP sequences. The iron concentration in date syrup was 2.6 mg/dL, and it was in ferric form. Images obtained after oral contrast administration had statistically significant improvement in gastrointestinal tract signal suppression (p < 0.001) and an increase in visibility of the common bile duct, cystic duct, and pancreatic duct (all p < 0.001). No adverse effects were noted in any of the patients. CONCLUSION: Date syrup can be used as a negative oral contrast agent for gastrointestinal tract signal suppression during MRCP and for improving visualization of various pancreaticobiliary structures.

Anisodamine accelerates spontaneous passage of single symptomatic bile duct stones ≤ 10 mm.

AIM: To investigate the rate of spontaneous passage of single and symptomatic common bile duct (CBD) stones ≤ 10 mm in diameter in 4 wk with or without a 2-wk course of anisodamine. METHODS: A multicenter, randomized, placebo-controlled trial was undertaken. A total of 197 patients who met the inclusion criteria were enrolled. Ninety-seven patients were assigned randomly to the control group and the other 100 to the anisodamine group. The anisodamine group received intravenous infusions of anisodamine (10 mg every 8 h) for 2 wk. The control group received the same volume of 0.9% isotonic saline for 2 wk. Patients underwent imaging studies and liver-function tests every week for 4 wk. The rate of spontaneous passage of CBD stones was analyzed. RESULTS: The rate of spontaneous passage of CBD stones was significantly higher in the anisodamine group than that in the control group (47.0% vs 22.7%). Most (87.2%, 41/47) stone passages in the anisodamine group occurred in the first 2 wk, and passages in the control group occurred at a comparable rate each week. Factors significantly increasing the possibility of spontaneous passage by univariate logistic regression analyses were stone diameter (< 5 mm vs ≥ 5 mm and ≤ 10 mm) and anisodamine therapy. Multivariate logistic regression analyses revealed that these two factors were significantly associated with spontaneous passage. CONCLUSION: Two weeks of anisodamine administration can safely accelerate spontaneous passage of single and symptomatic CBD stones ≤ 10 mm in diameter, especially for stones < 5 mm.

[Application of black tea as a negative oral contrast in magnetic resonance cholangiopancreatography (MRCP)].

OBJECTIVE: To investigate the feasibility of using black tea as a gastrointestinal oral negative contrast agent to null the signal from fluid in bowel during MR cholangiopancreatography (MRCP). METHODS: (1) 15 different drinks were scanned with MRCP, T2-map and T1-map in vitro to identify the most suitable drink for MRCP. (2) 10 volunteers were scanned by MRCP prior to and 5, 10, 15 min after tea consumptions to identify the optimal delay time. (3) 20 patients were scanned with MRCP prior to and 5 min after tea consumptions. The signal intensity (SI) and signal-to-noise ratio (SNR) of stomach, duodenum, liver-parenchyma, common bile duct (CBD), pancreatic duct (PD) and gall bladder (GB); the singal loss of stomach and duodenum; and the image quality of ampulla of vater (AV), intrahepatic ducts (IHD), hepatic duct, CBD, PD and GB were analyzed with Siemens Workstation. RESULTS: (1) Lipton black-tea was identified as the optimal drink in vitro. (2) There were no significant differences in MRCP among the 3 delay times in volunteer tests. (3) The SI, SNR and SI loss of stomach and duodenum, and the image quality of CBD, PD, GB and AV showed a significant improvement of MRCP after tea consumptions (P < 0.05). But tea consumptions made no significant differences in the image quality of IHD and hepatic duct, and the SI and SNR of liver, CBD, GB and PD (P > 0.05). CONCLUSION: As a simple, cheap and safe drink, black tea can be widely used to reduce signal intensity of gastrointestinal tract and provide improved image of MRCP.

Pancreas divisum: analysis and therapeutic alternatives with a case report.

INTRODUCTION: Pancreas divisum is a relatively common pancreatic duct anatomic variant, firstly described in the 17th century. CASE REPORT: We reported a 2-year-old child admitted to the Pediatric Clinic with breathing difficulties and abdominal pains. Examination and X-ray image, showed a vast right hydrothorax containing rusty coloured solution with a high degree of amylase. Ultrasound and computed tomography examination revealed pancreatic polycyclic pseudocysts; following magnetic resonance cholangiopancreatography (MRCP), the diagnosis of pancreas divisum was confirmed. The general condition of the patient worsened, requiring an urgent operation. External drainage of the perforated pancreatic pseudocyst was performed. Following external fistula maturation, a change from external to internal drainage was performed using Roux-en-Y fistulojejunostomy. A 3-year postoperative period was uneventful. CONCLUSION: Pancreas divisum cases are unique requiring clinical experience, rational approach, and complex multimodal management. MRCP is a valuable diagnostic method. Amongst therapeutic options, outer and internal drainage can be seen as reliable methods. Further investigations are absolutely required to determine practical and appropriate conclusions.

[Radiological diagnosis and intervention of cholangiocarcinomas (CC)]. / Radiologische Diagnostik und Intervention von Cholangiokarzinomen (CC).

To present current data on diagnosis, indication and different therapy options in patients with cholangiocarcinoma (CC) based on an analysis of the current literature and clinical experience. The diagnostic routine includes laboratory investigations with parameters of cholestasis and also serum tumor markers CA19 - 9 and CEA. After ultrasound for clarifying a tumor and/or dilated bile ducts, contrast-enhanced magnetic resonance imaging (MRI) should be performed with magnetic resonance cholangiography (MRCP). The accuracy (positive predictive value) for diagnosing a CC is 37-84% (depending on the location) for ultrasound, 79-94% for computed tomography (CT), and 95% for MRI and MRCP. An endoscopic retrograde cholangiography (ERCP) can then be planned, especially if biliary drainage or cytological or histological specimen sampling is intended. A curative approach can be achieved by surgical resection, rarely by liver transplantation. However, many patients are not eligible for surgery. In addition to systemic chemotherapy, locoregional therapies such as transarterial chemoembolization (TACE), hepatic arterial infusion (HAI)--also known as chemoperfusion--, drug eluting beads-therapy (DEB) as well as thermoablative procedures, such as laser-induced thermotherapy (LITT), microwave ablation (MWA) and radiofrequency ablation (RFA) can be provided with a palliative intention.

Improvement of MR cholangiopancreatography (MRCP) images after black tea consumption.

OBJECTIVE: Evaluation of the efficacy of black tea as the negative oral contrast agent in MRCP. MATERIALS AND METHODS: MRCP was performed before and 5 and 15 min after tea consumption for 35 patients. Depiction of the gall bladder (GB), cystic duct (CD), proximal and distal parts of the common bile duct (CBD), intrahepatic ducts (IHD), ampulla of vater (AV), main pancreatic duct (MPD) and signal loss of stomach and three different segments of the duodenum were investigated according to VAS and Likert scores. RESULTS: Twenty-one of the patients (60%) were female (mean age, 50.3 ± 19.2 years). Regarding visibility of different anatomical parts of the pancreatobiliary tree, the post procedure images were better visualized in the distal part of CBD, AV and MPD in Likert and VAS scoring (all P ≤ 0.001). Regarding obliteration of high signal in the stomach and three different parts of the duodenum, all post procedure images showed significant disappearance of high signal in Likert and VAS scoring systems (all Ps ≤ 0.001). CONCLUSION: Black tea is a simple and safe negative oral contrast agent which reduces the signal intensity of gastrointestinal tract fluid and provides improved depiction of the MPD, the distal CBD and the ampulla during MRCP. Key Points •Tea is an effective negative oral contrast agent for gastrointestinal MRI •Ingestion of black tea improves conspicuity of the distal CBD in MRCP.

Successful endoscopic procedures for intraductal papillary neoplasm of the bile duct: a case report.

Attention has recently been focused on biliary papillary tumors as the novel disease entity intraductal papillary neoplasm of the bile duct (IPNB), which consists of papillary proliferation of dysplastic biliary epithelium. As even benign papillary tumors are considered as premalignant, some investigators recommend aggressive surgical therapy for IPNB, although no guidelines are available to manage this disease. Few reports have described long-term follow-up of patients with benign IPNB without radical resection. If patients with IPNB who are treated only with endoscopic procedures are noted, clinical profiles and alternative therapies other than resection may be recommended. We report the case of a patient who experienced repetitive cholangitis for 10 years and was finally diagnosed with IPNB. Radical resection could not be recommended because of the age of the patient, therefore, endoscopic sphincterotomy was performed. Although an endoscopic retrograde biliary drainage catheter was placed several times for repetitive cholangitis, the patient has done well during follow-up. Our case may offer insights into the natural course and management decisions for the novel disease entity of IPNB.

Un caso de QT largo y torsades de pointes por ciprofloxacino / No disponible

No disponible

Clinical feasibility of Açai (Euterpe olerácea) pulp as an oral contrast agent for magnetic resonance cholangiopancreatography.

BACKGROUND: We evaluate the effectiveness of the Amazonian fruit pulp from Euterpe olerácea (popularly named Açaí) as a negative oral contrast agent applied to clinical routine. The use of such contrasts is particularly important in magnetic resonance cholangiopancreatography (MRCP) to reduce overlapping. MATERIALS AND METHODS: We administered Açaí pulp to 5 nonsymptomatic subjects and 35 patients submitted to unspecific abdominal MR imaging, intending to set up optimal protocol. In 8 MRCP examinations, contrast and image effects were assessed and graded blindly by 2 independent radiologists. Quantitative analysis was performed by Wilcoxon test as to verify the potential of the Açaí to eliminate overlap signal over the pancreaticobiliary tract. Adverse effects and subject tolerance were also addressed. RESULTS: The Açaí pulp elicited a local brightness decrease in T2-weighted images. The depiction of gallbladder, common bile duct, ampulla of Vater, and pancreatic duct was markedly improved after Açaí ingestion because of the suppression of the overlapping from bowel loops and gastric content (P < 0.01). All patients considered Açaí palatable, and no side effect was registered. CONCLUSIONS: The Açaí pulp can be used routinely in MRCP studies as a natural, safe, and inexpensive negative oral contrast agent with high efficacy and patient acceptance.

Gamma knife-treated hepatoma: case of obstructive jaundice and management.

Gamma knife therapy is becoming more frequently applied in solid tumor treatment. This article reports a unique case of severe obstructive jaundice arising as a complication of treatment of hepatoma at the hepatic hilum using a gamma knife.While planning an intervention, some images seem to promise success but actually lead to failure. Radiation damage to specific organs is difficult to predict because of several variables. Radiation-induced fibrosis and necrosis are the most common long-term adverse effects of radiotherapy; they are usually considered irreversible and result in induration and firmness of the tissue.To minimize radiation fibrosis, accurate patient positioning and tumor relocalization are essential for gamma knife use in the liver and other extracranial sites. Even when practiced frequently, any intervention must be delivered with caution if the liver has been treated with radiation. Otherwise, even with much experience, the unwary doctor can be trapped by deceptive images.

Main pancreatic duct intraductal papillary mucinous neoplasms: accuracy of MR imaging in differentiation between benign and malignant tumors compared with histopathologic analysis.

PURPOSE: To retrospectively determine the accuracy of magnetic resonance (MR) imaging combined with MR cholangiopancreatography (CP) in differentiating benign from malignant intraductal papillary mucinous neoplasms (IPMNs) involving the main pancreatic duct (MPD), with histopathologic analysis as the reference standard. MATERIALS AND METHODS: The informed consent requirement was waived for this institutional review board-approved study. A total of 51 patients with histopathologically proved IPMNs (MPD IPMN, n = 29; mixed type IPMN, n = 22), underwent MR imaging, MR CP, and surgery, with a mean interval of 2.6 months between MR examination and surgery. Qualitative image analysis included assessment of the site of MPD dilatation (head of the pancreas, body and/or tail of the pancreas, or diffuse), presence or absence of duct wall nodules, and contrast enhancement of the MPD walls. Quantitative image analysis included measurement of the maximum diameter of the MPD. A comparison of adenomas and borderline IPMNs with cancerous IPMNs was performed with the Student t test or the Mann-Whitney U test for continuous variables. RESULTS: At histopathologic analysis, 27 IPMNs were classified as carcinomas; 13, as borderline tumors; and 11, as adenomas. MPD wall nodules were observed in 16 carcinomas involving the MPD and one adenoma or borderline neoplasm (P < .00001). Duct wall enhancement was observed in 20 MPD or mixed type carcinomas and five adenomas or borderline neoplasms (P = .0001). The median maximal diameter of the MPD was 18 mm in malignant MPD or mixed type IPMNs and 11 mm in benign borderline IPMNs (P = .038). No significant difference in the overall 5-year survival rate of patients with MPD IPMNs and those with mixed type IPMNs was observed (P = .813). CONCLUSION: Duct wall nodules and enhancement of the MPD walls are signs of malignant MPD or mixed type IPMNs. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.2531080604/-/DC1.

Embolia aérea cerebral secundaria a colangiopancreatografía endoscópica retrógrada / Cerebral artery air embolism secondary to endoscopic retrograde cholangiopancreatography

El ictus cerebral secundario a embolias aéreas es una rara complicación de una endoscopia digestiva. Se presenta un caso de un paciente que desarrolló una embolia arterial cerebral durante la realización de una colangiopancreatografía retrógrada endoscópica. A pesar de su diagnóstico y tratamiento, el paciente falleció como consecuencia del grave daño cerebral isquémico. Las embolias aéreas cerebrales han representado, hasta ahora, una causa de ictus cerebral prácticamente anecdótica. Cada vez son más frecuentes y variadas las complicaciones secundarias a la realización de técnicas endoscópicas debido al gran aumento que este tipo de procedimientos ha experimentado en los hospitales españoles.El mejor conocimiento de esta rara complicación permite alcanzar un rápido diagnóstico, clave a la hora de aplicar su tratamiento específico y salvar la vida al paciente(AU)

Stroke secondary to an air embolism is an uncommon complication of gastrointestinal endoscopy. We report the case of a patient who developed a cerebral artery air embolism during endoscopic retrograde cholangiopancreatography. Despite diagnosis and treatment, the patient died from severe ischemic brain damage. To date, cerebral artery air embolisms as a cause of stroke have only been reported anecdotally. The complications of endoscopic techniques are increasingly frequent and varied, due to the major increase in the use of these procedures in our hospitals.Greater knowledge of this infrequent complication would allow rapid diagnosis, which is essential to provide specific treatment and prevent fatal outcome(AU)

A prospective trial on the correllation of consensus definition of post-ERCP pancreatitis, CT findings and clinical diagnosis of pancreatitis: are the old concepts coming down?

Background: The consensus definition of post-ERCP pancreatitis is abdominal pain 24 hours following ERCP along with greater than 3-fold serum amylase eleva»tion. The authors evaluated if there was a correlation between the consensus definition and CT findings of pancreatitis. Methods: 300 patients were followed pro»spectively after ERCP regarding development of pan»creatitis. Patients developing pain underwent amylase testing and abdominal CT scan. Pancreatitis on CT was classified by the Balthazar classification. The pri»mary outcome measurement was the correlation be»tween the consensus definition of post-ERCP pancre»atitis and CT findings of pancreatitis. Results: Out of the patients submitted to the study, 49 presented ab»dominal pain in the 24 hours following examination. Of these, 38 (12.6%) had radiological alterations com-patible with pancreatitis and 23 (7.6%) a > 3-fold serum amylase elevation. Selective cannulation of the biliary duct with guidewire revealed a lower incidence (p = 0.037) and severity (p = 0.002) of pancreatites than cannulation without guidewire. Ali patients had a low-intensity pancreatitis according to Ranson's cri»teria. There were no procedure-related deaths. Con»clusions: The best parameter for the diagnosis of post»ERCP pancreatitis is the tomographic control before and after the procedure, with amylase elevation (three times) having 52.6% sensitivity, 72.7% specificity and 57.1% accuracy.

[Intraductal photo-irradiation of bile in complex treatment of patients with cholangitis].

The authors have analyzed results of complex treatment of cholangitis patients by the application of intraductal photoirradiation. This method of treatment was shown to give more favorable course of the postoperative period.

Chylous ascites secondary to pancreatitis: management of an uncommon entity using parenteral nutrition and octreotide.

Malignancy, surgical trauma, cirrhosis and tuberculosis account for more than 95% of causes for chylous ascites. We report a case of persistent chylous ascites following acute pancreatitis that responded to parenteral nutrition and octreotide. A 50 year-old male was diagnosed with acute alcoholic pancreatitis after presenting with typical abdominal pain, and elevated amylase and lipase. The acute symptoms resolved within one week. Four weeks later he started developing increased abdominal girth. Examination revealed the presence of shifting dullness and paracentesis confirmed diagnosis of chylous ascites. Investigations for the common causes of chylous ascites were negative. Laparoscopy confirmed the presence of fat necrosis within mesenteric lymph nodes linking the chylous ascites to the episode of pancreatitis. The Chylous ascites was resistant to the usual medical therapy, but responded only to the combination of octreotide and total parenteral nutrition with complete resolution of ascites in 8 weeks. This case of chylous ascites secondary to pancreatitis represents an uncommon presentation with effective management resulting in a dramatic response.