Revisión bibliográfica de Fasciolosis biliar: propósito de un caso / Bibliographic review of biliary fasciolosis: purpose of a case

The biliary pathology, is undoubtedly one of the most frequent surgical pathologies in Chile, statistical data establish the incidence of biliary pathology in over 20 years 30% of women have biliary lithiasis, of these 10% will present some complication as it is coledocolithiasis. On the other hand, hepatic fascioliasis or dystomatosis is a disease caused by hepatic fasciola, or duela, sabuaypé or Distomun hepaticum, corresponds to a flatworm, trematode of the digenea class, with affinity to stay in liver tissue, which when performing the biological cycle of the parasite can be the cause of choledocholithiasis, cholecystitis, cholangitis, pancreatitis, among others. We present a clinical case of chronic intracholedocianfasciolitis diagnosed by ERCP3,4. METHODS: Descriptive observational study, in addition to a systematic review in databases such as Pub-Med/MEDLINE, Elsevier, Cochrane and manually through the Internet in journals and public bodies. This work seeks to collect information from different authors regarding its incidence, management and established treatments. RESULTS: Inclusion and exclusion criteria were defined to analyze the characteristics of the selected articles. We present the clinical case of a 47-year-old female patient, with a history of hypertension, type 2 diabetes mellitus and egg allergy who went to the Emergency Department due to a picture characterized by epigastralgia of 3 days of evolution. During endoscopic retrograde cholangio-pancreatography (ERCP), 2 suggestive images of lyte are seen inside that finally result in 2 apparent live parasites.

Colangiografia transcolecística percutânea em cães e gatos: nova técnica diagnóstica em medicina veterinária / Percutaneous transcholecystic cholangiography in dogs and cats: new diagnostic technique in veterinary medicine / Colangiografía transcolecística percutánea en perros y gatos: nueva técnica diagnóstica en medicina veterinária

Os métodos de diagnóstico por imagem para investigação das obstruções biliares atualmente disponíveis na medicina veterinária apresentam algumas limitações, como sensibilidade diagnóstica insuficiente e alto custo. Neste contexto, o presente trabalho objetivou padronizar e descrever a técnica de colangiografia transcolecística percutânea em cães e gatos, consistindo na injeção de contraste no interior das vias biliares por colecistocentese ecoguiada seguida de avaliação radiográfica abdominal. Os animais não apresentaram quaisquer efeitos colaterais decorrentes da técnica e a mesma apresentou eficácia na demonstração radiográfica da árvore biliar, possibilitando a investigação diagnóstica das enfermidades obstrutivas que acometem as vias biliares nas espécies canina e felina.

Imaging methods for investigation of biliary obstructions currently available in veterinary medicine present some limitations, such as insufficient diagnostic sensitivity and high cost. In this context, the objective of the present study was to standardize and describe the technique of percutaneous transcholecystic cholangiography in dogs and cats, consisting of the injection of contrast inside the bile ducts by ultrasound-guided cholecystocentesis followed by abdominal radiographic evaluation. The animals did not present any side effects resulting from the technique and it showed efficacy in the radiographic demonstration of the biliary tree, making possible the diagnostic investigation of the obstructive diseases that affect the bile ducts in the canine and feline species.

Los métodos de diagnóstico por imagen para investigación de las obstrucciones biliares actualmente disponibles en la medicina veterinaria presentan algunas limitaciones, como sensibilidad diagnóstica insuficiente y alto costo. En este contexto, el presente trabajo objetivó estandarizar y describir la técnica de colangiografía transcolecística percutánea en perros y gatos, consistente en la inyección de contraste en el interior de las vías biliares por colecistocentes y ecoguiada seguida de evaluación radiográfica abdominal. Los animales no presentaron efectos colaterales derivados de la técnica y la misma presentó eficacia en la demostración radiográfica del árbol billar, posibilitando la investigación diagnóstica de las enfermedades obstructivas que acomete las vías biliares en las especies canina y felina.

Colangiografia transcolecística percutânea em cães e gatos: nova técnica diagnóstica em medicina veterinária / Percutaneous transcholecystic cholangiography in dogs and cats: new diagnostic technique in veterinary medicine / Colangiografía transcolecística percutánea en perros y gatos: nueva técnica diagnóstica en medicina veterinária

Os métodos de diagnóstico por imagem para investigação das obstruções biliares atualmente disponíveis na medicina veterinária apresentam algumas limitações, como sensibilidade diagnóstica insuficiente e alto custo. Neste contexto, o presente trabalho objetivou padronizar e descrever a técnica de colangiografia transcolecística percutânea em cães e gatos, consistindo na injeção de contraste no interior das vias biliares por colecistocentese ecoguiada seguida de avaliação radiográfica abdominal. Os animais não apresentaram quaisquer efeitos colaterais decorrentes da técnica e a mesma apresentou eficácia na demonstração radiográfica da árvore biliar, possibilitando a investigação diagnóstica das enfermidades obstrutivas que acometem as vias biliares nas espécies canina e felina.(AU)

Imaging methods for investigation of biliary obstructions currently available in veterinary medicine present some limitations, such as insufficient diagnostic sensitivity and high cost. In this context, the objective of the present study was to standardize and describe the technique of percutaneous transcholecystic cholangiography in dogs and cats, consisting of the injection of contrast inside the bile ducts by ultrasound-guided cholecystocentesis followed by abdominal radiographic evaluation. The animals did not present any side effects resulting from the technique and it showed efficacy in the radiographic demonstration of the biliary tree, making possible the diagnostic investigation of the obstructive diseases that affect the bile ducts in the canine and feline species.(AU)

Los métodos de diagnóstico por imagen para investigación de las obstrucciones biliares actualmente disponibles en la medicina veterinaria presentan algunas limitaciones, como sensibilidad diagnóstica insuficiente y alto costo. En este contexto, el presente trabajo objetivó estandarizar y describir la técnica de colangiografía transcolecística percutánea en perros y gatos, consistente en la inyección de contraste en el interior de las vías biliares por colecistocentes y ecoguiada seguida de evaluación radiográfica abdominal. Los animales no presentaron efectos colaterales derivados de la técnica y la misma presentó eficacia en la demostración radiográfica del árbol billar, posibilitando la investigación diagnóstica de las enfermedades obstructivas que acomete las vías biliares en las especies canina y felina.(AU)

THE USE OF THE FORCEPS BIOPSY AS AN AUXILIARY TECHNIQUE FOR THE VISUALIZATION OF THE MAJOR DUODENAL PAPILLA USING THE FOWARD-VIEWING UPPER ENDOSCOPY.

BACKGROUND: - Conventional esophagogastroduodenoscopy is the best method for evaluation of the upper gastrointestinal tract, but it has limitations for the identification of the major duodenal papilla, even after the use of the straightening maneuver. Side-viewing duodenoscope is recommended for optimal examination of major duodenal papilla in patients at high risk for lesions in this region. OBJECTIVE: To evaluate the use of the biopsy forceps during conventional esophagogastroduodenoscopy as an additional tool to the straightening maneuver, in the evaluation of the major duodenal papilla. METHODS: A total of 671 patients were studied between 2013 and 2015, with active major duodenal papilla search in three endoscope steps: not straightened, straightened and use of the biopsy forceps after straightening. In all of them it was recorded whether: major duodenal papilla was fully visualized (position A), partially visualized (position B) or not visualized (position C). If major duodenal papilla was not fully visualized, patients continued to the next step. RESULTS: A total of 341 were female (50.8%) with mean age of 49 years. Of the 671 patients, 324 (48.3%) major duodenal papilla was identified in position A, 112 (16.7%) in position B and 235 (35%) in position C. In the 347 patients who underwent the straightening maneuver, position A was found in 186 (53.6%), position B in 51 (14.7%) and position C in 110 (31.7%). Of the 161 remaining patients and after biopsy forceps use, position A was seen in 94 (58.4%), position B in 14 (8.7%) and position C in 53 (32.9%). The overall rate of complete visualization of major duodenal papilla was 90%. CONCLUSION: The use of the biopsy forceps significantly increased the total major duodenal papilla visualization rate by 14%, reaching 604/671 (90%) of the patients (P<0.01) and it can be easily incorporated into the routine endoscopic examination of the upper gastrointestinal tract.

O uso da pinça de biópsia como técnica auxiliar na visualização da papila duodenal maior utilizando-se o esofagogastroduodenoscópio de visão frontal / The use of the forceps biopsy as an auxiliary technique for the visualization of the major duodenal papilla using the foward-viewing upper endoscopy

ABSTRACT BACKGROUND: - Conventional esophagogastroduodenoscopy is the best method for evaluation of the upper gastrointestinal tract, but it has limitations for the identification of the major duodenal papilla, even after the use of the straightening maneuver. Side-viewing duodenoscope is recommended for optimal examination of major duodenal papilla in patients at high risk for lesions in this region. OBJECTIVE: To evaluate the use of the biopsy forceps during conventional esophagogastroduodenoscopy as an additional tool to the straightening maneuver, in the evaluation of the major duodenal papilla. METHODS: A total of 671 patients were studied between 2013 and 2015, with active major duodenal papilla search in three endoscope steps: not straightened, straightened and use of the biopsy forceps after straightening. In all of them it was recorded whether: major duodenal papilla was fully visualized (position A), partially visualized (position B) or not visualized (position C). If major duodenal papilla was not fully visualized, patients continued to the next step. RESULTS: A total of 341 were female (50.8%) with mean age of 49 years. Of the 671 patients, 324 (48.3%) major duodenal papilla was identified in position A, 112 (16.7%) in position B and 235 (35%) in position C. In the 347 patients who underwent the straightening maneuver, position A was found in 186 (53.6%), position B in 51 (14.7%) and position C in 110 (31.7%). Of the 161 remaining patients and after biopsy forceps use, position A was seen in 94 (58.4%), position B in 14 (8.7%) and position C in 53 (32.9%). The overall rate of complete visualization of major duodenal papilla was 90%. CONCLUSION: The use of the biopsy forceps significantly increased the total major duodenal papilla visualization rate by 14%, reaching 604/671 (90%) of the patients (P<0.01) and it can be easily incorporated into the routine endoscopic examination of the upper gastrointestinal tract.

RESUMO CONTEXTO: Esofagogastroduodenoscopia convencional é o melhor método para avaliação do trato gastrointestinal superior, mas apresenta limitações para identificação da papila duodenal maior, mesmo após emprego da manobra de retificação. Exame completo da papila duodenal maior está indicado para pacientes de alto risco para adenocarcinoma da papila duodenal maior. OBJETIVO: Avaliar a utilização da pinça de biópsia durante esofagogastroduodenoscopia convencional como ferramenta adicional à manobra de retificação na avaliação da papila duodenal maior. MÉTODOS: Foram estudados 671 pacientes entre 2013-2015 com busca ativa da papila duodenal maior em três etapas: endoscópio não retificado, endoscópio retificado e uso da pinça de biópsia após retificação. Em todas se registrou: se a papila duodenal maior foi totalmente visualizada (posição A), se parcialmente visualizada (posição B) ou se não visualizada (posição C). Caso a papila duodenal maior não tenha sido completamente visualizada, o paciente foi direcionado para a etapa seguinte. RESULTADOS: Um total de 341 era do sexo feminino (50,8%) com idade média de 49 anos. Dos 671 pacientes, em 324 (48,3%) a papila duodenal maior foi identificada na posição A, 112 (16,7%) em posição B e, 235 (35%) em posição C. Dos 347 pacientes submetidos à manobra de retificação, posição A foi encontrada em 186 (53,6%), posição B em 51 (14,7%) e posição C em 110 (31,7%). Dos 161 pacientes restantes que utilizaram a pinça de biópsia, posição A foi vista em 94 (58,4%), posição B em 14 (8,7%) e posição C em 53 (32,9%). A taxa acumulativa de visualização completa da papila duodenal maior foi de 90%. CONCLUSÃO: O uso da pinça de biópsia aumentou a taxa de visualização completa da papila duodenal maior em 14%, alcançando 604/671 (90%) dos pacientes (P<0,01) avaliados e pode ser facilmente incorporada aos exames endoscópicos de rotina do trato gastrointestinal superior.

[Echinococcosis of intra- and extrahepatic bile ducts. Report of a case at the Central Military Hospital]. / Hidatidosis en vías biliares intra y extrahepáticas. Reporte de un caso en el Hospital Militar Central.

We present a woman 34 years old with echinococcosis of intra and extra hepatic biliary ducts including gallbladder. We found alive cysts, dead cysts and fragments of germinative membranes of a complicated cyst in left lobe (I - II) with clinical findings of obstructive jaundice; pain; cholecystitis and great dilation of biliary ducts. We performed left lobectomy, exploration of biliary ducts, transduodenal sphincteroplasty, cholecystectomy. We haven't had complications. We present ultrasound images of the pathologic pieces.

[Endoscopic cholangiography in biliary tract diseases in HIV+ patients]. / La colangiografía endoscópica en afecciones de la vía biliar en pacientes HIV+.

UNLABELLED: Biliary tract involvement in the course of the infection by HIV was first described in 1983. Since then, various opportunistic infections have been responsible of different biliary lesions, coming to a new entity called "cholangiopathy associated to HIV". Our aim was to determined the use of ERCP in the management of HIV patients with cholestasis. From August 1994 to October 1997, 11 HIV patients (8 men, 3 women, mean age 35 y.) were submitted to ERCP because of jaundice (n = 8), upper right abdominal pain (n = 8), fever (n = 6), pruritus (n = 5) and elevated alkaline phosphatase (n-10). In 7 the diagnosis of AIDS had already be made. All had hepatobiliary ultrasound and endoscopic periampullar duodenal mucosa biopsy was taken in 7. According to Cello, 4 types of radiologic lesions were considered: 1) Papillary stenosis with dilated extrahepatic biliary tract. 2) Sclerosing cholangitis (focal intra or extrahepatic stenosis and dilatations). 3) Association of types 1 and 2.4) Choledocal long stenosis in the absence of previous biliary surgery or chronic pancreatitis. Five patients (45%) had biliary abnormalities; in 3 related to HIV infection: sclerosing cholangitis (n = 2) and papillary stenosis (n = 1). Two had choledocal stones. Four had upper right abdominal pain and dilated bile ducts at ultrasound. Cryptosporidium was found in duodenal mucosa in one patient with sclerosing cholangitis and in the patient with papillary stenosis. Biliary stents were placed without sphincterotomy in 2, with relief of pain and improving of cholestasis in only one. The choledocal stones were removed endoscopically in one patient and by surgery in the other. CONCLUSION: The ERCP is a useful method in the diagnosis and treatment of the biliary tract abnormalities associated to HIV.

La colangiografia endoscopica en afecciones de la via biliar en pacientes HIV+ / Endoscopic cholangiography in biliary tract diseases in HIV+ patients

El compromiso de la vía biliar en el curso de la infección por HIV se describió por primera vez en 1983. Desde entonces diversas infecciones oportunistas han sido responsables de lesiones biliares, definiendo una nueva entidad denominada colangiopatía asociada al HIV. Nuestro objetivo fue determinar la utilidad de la CPRE en el manejo de pacientes HIV + con colestasis. Desde agosto de 1994 a octubre de 1997 se efectuó CPRE en 11 HIV + (8 hombres, 3 mujeres, con edad promedio 35 años). La indicación de CPRE fue por ictericia (n=8); dolar en HD (n=8); fiebre (n=6); prurito (n=5) y aumento de la FA (n=10). Siete pacientes tenían Sida. En todos se realizó ecografía hepatobiliar. En 7 se tomó biopsia de la mucosa duodenal periampular. Las lesiones radiológicas se clasificaron según Cello en: 1- Estenosis papilar, con dilatación de la vía biliar extrahepática. 2- Colangitis esclerosantes (estenosis y dilataciones focales, intra y/o extrahepáticas). 3- Asociación de 1 y 2. 4- Estenosis larga del colédoco, en ausencia de cirurgía biliar o pancreatitis crónica. Cinco pacientes (45 por ciento) tuvieron anormalidades en la vía biliar. En 3 de ellos estuvieron relacionadas con la infección HIV: colangitis esclerosantes (n=2) y estenosis papilar (n=1). Dos presentaban litiasis coledociana. Cuatro de los 5 tuvieron dolor en HD y vía biliar dilatada en la ecografía. Se encontró Cryptosporidium en la biopsia duodenal de 1 paciente con colangitis esclerosante y en la estenosis papilar. Se colocó prótesis biliar sin esfinteropapilotomía en 2, con alivio del dolor y mejoría de la colestasis en uno de ellos. Los cálculos coledocianos se extrajeron endoscópicamente en uno y por cirugía en otro. Conclusión: La CPRE fue un método útil en el diagnóstico y tratamiento de las patologías biliares asociadas al HIV. (AU)

Sphincter of Oddi in health and disease.

Sphincter of Oddi (SO) is a dynamic structure located strategically at the confluence of the bile duct, the pancreatic duct and the duodenum. The advent of lateral viewing endoscope along with a minimally compliant pneumocapillary manometry system has greatly enhanced our ability to evaluate the SO in health and disease. These studies have shown that the SO motor function is a complex phenomenon controlled by a variety of neurohumoral agents. The sphincter also actively participates in the Migratory Motor Complex (MMC). The major function of the SO seems to be in regulating the flow of bile and pancreatic juice into the duodenum. By maintaining a basal tone, the sphincter diverts bile into the gallbladder under fasting conditions. On the other hand it functions as "a pump" as well to milk bile into the duodenum. Recent manometric studies also have unravelled a number of abnormalities involving the SO motor function often referred to as SO dysfunction. Most such patients respond favorably to sphincter ablation. Studies are underway to better define patients with SO dysfunction as well as to identify them using noninvasive investigations.

Ultrasound in the diagnosis of roundworms in gallbladder and common bile duct. Report of four cases.

Four patients who complained of symptoms and signs compatible with biliary tract disease and in whom the diagnosis of gallbladder (three cases) and common bile duct ascariasis (one case) was made sonographically are reported. In two patients with gallbladder ascariasis, cholecystectomy corroborated the presence of the round-worms, and was curative. The third patient was a pregnant woman (32nd gestational week) who took piperazine citrate, and a second sonogram performed 29 days later was completely normal. The fourth patient with common bile duct ascariasis underwent choledochotomy with extraction of one ascaris lumbricoides from the common duct, and a T tube was left in place for 15 days. All patients received antiparasitics and had a favorable outcome. Ultrasonography is an important noninvasive diagnostic procedure in the work-up of these patients, who usually describe a clinical picture suggesting gallstone disease: this is especially true in the presence of pregnancy.

Choledochoduodenal fistulas.

In 2,012 ERCP studies reviewed in the period between 1976 and 1989, we observed 14 choledochoduodenal fistulas found in the upper portion of the papilla of Vater. Two fistulas occurred spontaneously due to necrosis of the duodenal wall caused by stones located in the distal common bile duct above the sphincter of the papilla. In these two cases the stones were removed endoscopically. The twelve remaining cases were iatrogenic, caused during surgical papillotomy which resulted in a false tract. All patients showed raised AP and gamma GT. Eight had acute cholangitis, 7 were jaundiced, there was one case each of acute pancreatitis and chronic recurrent pancreatitis. Nine patients had stones located in the distal common bile duct. In eight cases it was possible to cannulate the papillary opening and do a papillotomy thereby connecting the fistulous orifice with the opening of the papilla. The other patient was treated surgically. Two patients had papillary stenosis. One was successfully treated with papillotomy through the papillary opening. In the other, the fistulous orifice was joined with the papillary opening using a diathermy scalpel. This patient suffered a posterior duodenal wall perforation. One patient with acute pancreatitis and common bile duct stones distal to the fistula improved with papillotomy and stone removal. The patient with chronic recurrent pancreatitis without lithiasis refused any form of treatment.

[Benign common bile duct stenosis: percutaneous dilatation in a case]. / Estenosis benigna de via biliar: dilatación percutánea en un caso.

A 41 year old woman developed obstructive biliary tract disease 3 years after cholecystectomy. A surgical attempt to relieve the obstruction failed and a benign stricture of the common duct was shown at cholangiography. Percutaneous dilatation of the stricture was performed through the draining tube with excellent clinical and laboratory results.

Surgical treatment of chronic pancreatic cholangiopathy.

In a consecutive surgical series of 70 patients with chronic calcifying pancreatitis, 18 presented with fixed stenosis of the terminal common bile duct. Nine patients presented with jaundice and two had a palpable gallbladder. The most relevant laboratory datum in the series was a persistently high serum alkaline phosphatase level. Long tapering of the terminal common bile duct was the characteristic radiological sign in 45 of our patients. In five of the 18 cases compression of the terminal bile duct was due to cephalic pseudocysts. Hepaticojejunostomy-en-Y was the type of drainage chosen in 16 cases, and an end-to-side technique was used in 15 patients. Side-to-side choledochoduodenostomy was performed in two cases. In 14 patients, biliary drainage was associated with other surgical procedures on the pancreatic parenchyma. No postoperative complications due to the biliary drainage occurred in this series.

[Hepatic fibropolycystic disease in Mexico. Study of 82 cases]. / Enfermedad fibropoliquística hepática en Mexico. Estudio de 82 casos.

We analyzed 82 cases of hepatobiliary fibropolycystic disease (FPD) that were seen at the Instituto Nacional de la Nutrición "Salvador Zubirán" in Mexico City in the thirty-year period comprised from 1956 to 1986. The different entities that compose FPD were distributed as follows: 61 (74%) cases of polycystic liver disease, 13 (16%) cases of choledochal cyst, and 8 (10%) cases of congenital hepatic fibrosis; there were 5 (6%) cases of Caroli's disease, 3 associated with congenital hepatic fibrosis and 2 with choledochal cyst. Polycystic liver disease predominated in females (67%) and presented at 54 +/- 12 years (mean +/- SEM) with pain, a mass, symptoms related to renal insufficiency or incidentally; polycystic kidneys were present in 61%. Liver function tests were normal in 94%. Choledochal cyst also predominated in females and presented at a mean age of 19 years with cholangitis. Liver function tests were abnormal in 69%. Congenital hepatic fibrosis (50% male) presented with variceal hemorrhage or cholangitis (in 3 patients associated with Caroli's disease). Polycystic kidneys were present in five patients. Four of the five patients with Caroli's disease were female and presented at a mean age of 19 years with cholangitis. It never presented as an isolated disease, but was associated more frequently to congenital hepatic fibrosis. The diseases that are part of the hepatobiliary polycystic disease vary in severity and thus the prognosis in an individual patient is determined by the type of fibropolycystic disease present. This is the largest series of this disease published in our country.