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Endoscopic sphincterotomy (ES) is indicated in patients with confirmed bile duct stones at endoscopic retrograde cholangiopancreatography (ERCP). The role of ES in patients with suspected bile duct stones but a normal cholangiogram, in the prevention of recurrent biliary symptoms, when cholecystectomy is not planned, is unclear. To determine if prophylactic ES prevents further biliary problems in such patients. Patients were identified with gallbladder stones presenting with jaundice, abnormal liver function tests (LFTs) or dilated bile ducts on ultrasound, in whom cholecystectomy was not planned and who had a normal cholangiogram at ERCP. Patients were followed-up to determine the frequency of recurrent biliary problems or repeat investigations. Forty-one patients were included, of whom 20 had an ES. The frequency of pre-ERCP features did not differ between the two groups. Median follow-up was 32 months (range 15–66). Post-ERCP recurrent abdominal pain (5 vs 3; p=0.39), jaundice (3 vs 1; p=0.28), pancreatitis (0 vs 1; p=0.32), and repeat ultrasound (2 vs 1; p=0.52), ERCP (1 vs 1; p=0.97) or cholecystectomy (2 vs 3, p=0.82) did not differ between the two groups. Patients with gallstones, suspected common bile duct (CBD) stones and a normal cholangiogram need not have a prophylactic sphincterotomy since there is no reduction in recurrent biliary problems and this potentially increases the morbidity. [ABSTRACT FROM AUTHOR]

Postoperative biliary complications following extensive hepatic resections are complex, often requiring a multidisciplinary team approach. We describe a case of a free bile duct leak following extended right hepatectomy and surgical hepaticojejunostomy treated with percutaneous transhepatic hepaticojejunostomy in which a radiofrequency guidewire was used to gain enteral access. A modified internal/external biliary catheter was left in place. The patient was enrolled in a benign biliary stricture protocol, and 8 months later, the catheter was removed following a normal cholangiogram and biliary manometric perfusion testing. At 3-month follow-up after catheter removal, the patient is asymptomatic with no clinical, biochemical, or radiographic evidence of biliary leak or obstruction. [ABSTRACT FROM AUTHOR]

Inflammatory bowel disease (IBD) is frequently associated with extraintestinal manifestations such as hepatopancreatobiliary manifestations (HPBMs), which include primary sclerosing cholangitis (PSC), pancreatitis, and cholelithiasis. PSC is correlated with IBD, particularly ulcerative colitis (UC); 70-80% of PSC patients in Western countries and 20-30% in Japan have comorbid UC. Therefore, patients diagnosed with PSC should be screened for UC by total colonoscopy. While symptoms of PSC-associated UC are usually milder than PSC-negative UC, these patients have a higher risk of colorectal cancer, particularly in the proximal colon. Therefore, regular colonoscopy surveillance is required regardless of UC symptoms. Administration of 5-aminosalicylic acid or ursodeoxycholic acid may prevent colorectal cancer and cholangiocarcinoma. While PSC is diagnosed by diffuse multifocal strictures on cholangiography, it must be carefully differentiated from immunoglobulin G4 (IgG4)-associated cholangitis, which shows a similar cholangiogram but requires different treatment. When PSC is suspected despite a normal cholangiogram, the patient may have small-duct PSC, which requires a liver biopsy. IBD patients have a high incidence of acute and chronic pancreatitis. Most cases are induced by cholelithiasis or medication, although some patients may have autoimmune pancreatitis (AIP), most commonly type 2 without elevation of serum IgG4. AIP should be accurately identified based on characteristic image findings, because AIP responds well to corticosteroids. Crohn's disease is frequently associated with gallstones, and several risk factors are indicated. HPBMs may influence the management of IBD, therefore, accurate diagnosis and an appropriate therapeutic strategy are important, as treatment depends upon the type of HPBM. [ABSTRACT FROM AUTHOR]

Background and aims: Information about the natural history of small duct primary sclerosing cholangitis (SDPSC) remains scant despite literature suggesting that it constitutes 6-16% of all cases of primary sclerosing cholangitis (PSC). We combined clinical data on SDPSC cases from two tertiary care institutions with liver transplantation programs with the aim of studying the natural history of SDPSC. Methods: Medical records of 25 individuals with SDPSC were reviewed. Diagnosis of SDPSC was based on liver biopsy findings consistent with PSC, a normal cholangiogram, and elimination of known causes of secondary sclerosing cholangitis. Demographic information, symptoms, past medical history, laboratory values, and histologic data were evaluated. Our primary outcome measure was liver transplantation or death. Secondary outcome measures included evidence of end-stage liver disease, development of cholangiocarcinoma, and/or the development of classic PSC on a repeat cholangiogram. Results: Data on 25 individuals (13 males, 12 females; mean age 40 ± 15 years) diagnosed with SDPSC were analyzed. Upon presentation, 11 patients had symptoms including abdominal pain, fatigue, and pruritus. Inflammatory bowel disease was present in 14 patients (56%) at diagnosis. On initial liver biopsy, 60% had early-stage disease (I or II) and none had cirrhosis. On follow-up (1-168 months, median 17 months), malignancy or progression to classic large duct PSC was not noted. Two (8%) patients had evidence of varices and one of the two also developed ascites; one of these patients underwent liver transplantation and the other one died due to sepsis. Conclusions: SDPSC, a mild disease at presentation typically runs a benign course and likely is not an early stage of classic PSC. Further studies with a control group of classic PSC and longer follow-up are needed to study the natural history of SDPSC. [ABSTRACT FROM AUTHOR]

In order to clarify the pathogenesis and process of the formation of intrahepatic cholesterol gallstones, we examined the clinical features, cholangiograms and pathological findings of eight patients with intrahepatic cholesterol gallstones. When examining the clinical features, one patient was found to have developed intrahepatic cholesterol gallstones 3 years after a complete lithotomy. The cholangiograms of two patients revealed small gallstones in the peripheral bile ducts of the lateral segment of the liver, and these bile ducts showed localized cystic dilatation and were tightly filled with gallstones. Conversely, their other bile ducts which contained no gallstones showed an entirely normal cholangiogram. Pathologically, these two cases showed mild chronic cholangitis, and cholesterol crystals in the peripheral bile ducts. The other six cases showed moderate or severe dilatation of the bile duct and severe chronic proliferative cholangitis. From the above results, we proposed the following theory to explain the pathogenesis and process of the formation of intrahepatic cholesterol stones: The cholesterol crystals in the peripheral intrahepatic bile ducts may be a primitive form of intrahepatic cholesterol gallstones, and the formation of intrahepatic cholesterol gallstones may precede and cause such deformities of the bile ducts as strictures or dilatations. [ABSTRACT FROM AUTHOR]

Patients with cholestatic liver function tests and histological features of primary sclerosing cholangitis (PSC) but without the typical cholangiographic changes are considered to have small-duct PSC. The incidence of small-duct PSC and the natural history still is not known. We performed a retrospective search for patients diagnosed with small-duct PSC between January 1997 and December 2003. The diagnosis of small-duct PSC was based on biochemical features of chronic cholestasis, liver biopsy findings consistent with PSC, and a normal cholangiogram on endoscopic retrograde cholangiography. Six patients fulfilled the diagnostic criteria for small-duct PSC. All patients received medical therapy. After a mean follow-up time of 26.0 ± 29.8 months (range, 7–84 months), all patients are alive. Repeated liver biopsy was performed in one patient, 58 months after the initial one, and disclosed amelioration of histological findings (reduction in the Ludwig fibrosis score from 4 to 2). During follow-up symptoms disappeared in all patients who were symptomatic at diagnosis; none of those who were asymptomatic at diagnosis developed symptoms. At the time of last follow-up all patients showed significant improvement of their biochemical variables compared to baseline. Administration of aminosalicylates seemed to be of benefit irrespective of the presence of inflammatory bowel disease. No patients underwent liver transplantation or developed cholangiocarcinoma. Even though our study included a low number of patients and the follow-up time was relatively short, we can suggest that small-duct PSC rarely progresses to large-duct PSC and does not seem to be associated with development of cholangiocarcinoma. It thus seems to represent a separate entity with a favorable prognosis. [ABSTRACT FROM AUTHOR]

Spontaneous perforation of the biliary tract is rare in infants & children with less than 100 cases reported in English Literature till date. We report two cases of this rare clinical entity in a 9-month-old boy and other of a 2-year old boy. Both patients presented with clinical features of acute peritonitis. Laparotomy revealed sterile biliary peritonitis with a normal cholangiogram in the infant and biliary perforation in other child. Simple drainage in the former and cholecystostomy with external biliary drainage in later resulted in a satisfactory outcome. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study is to confirm the effectiveness of total laparoscopic treatment of common bile duct (CBD) stones in children. Methods: All children who were treated in our department for cholelithiasis were reviewed from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications, and stone-free status or not, at last follow-up. Results: 551 children were treated for cholelithiasis and had undergone laparoscopic cholecystectomy. Among those, 36 children (6.5 %) presented with CBD stones with a mean age at symptom onset of 10.4 years (min-max: 4 months-18 years). A majority of the patients presented with hemolytic disease (61 %). In 55 % of the cases, cholangiography alone or simple serum saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter led to 72 % of success rate. In 9 cases (25 %) of failure of the procedure, 6 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES), 1 patient was re-operated at day1 for hemorrhage, and 2 patients were followed by US scan with spontaneous evacuation of CBD stones. Mean follow-up was of 2 years (min-max: 1 month-5 years). All patients were stone free at last clinical and radiological evaluation. Conclusion: A one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72 % of the cases. This rate could be upgraded by a combination of laparoscopic and endoscopic technique during the same anesthesia and preserving Oddi sphincter function. These minimal invasive techniques still need to be developed in children. [ABSTRACT FROM AUTHOR]

Patients with cholestatic liver tests and typical histologic features of primary sclerosing cholangitis (PSC) but a normal cholangiogram have been identified as having small-duct PSC. This subgroup of PSC has been less well characterized than the classic largeduct form. Some patients characterized as having small-duct PSC develop cholangiographic features of PSC during follow-up. Three papers published in 2002 on small-duct PSC patients suggested a better prognosis in patients with small-duct PSC than in those with large-duct PSC. However, these studies included a limited number of patients and had a short follow-up. A combined cohort of these patients with a prolonged follow-up recently confirmed these previous observations. However, some patients will suffer from liver-related mortality or will need to undergo liver transplantation. Recurrence of small-duct PSC after liver transplantation has been reported. Cholangiocarcinoma, the most feared complication of PSC, has not been described in a patient with small-duct PSC without progression first to large-duct PSC. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a leading modality for treatment of biliary and pancreatic disease but is not widely available in sub-Saharan Africa. We aimed to assess the development and outcomes of an ERCP service in southwestern Kenya, including case volumes, success rates, infrastructure, and training. Methods: We conducted a retrospective review of all ERCPs performed at Tenwek Hospital in Bomet, Kenya between January 1, 2011 and March 31, 2020. Results: In total 277 ERCP procedures were attempted during the study period. The commonest indication was obstructive jaundice: 91 patients (32.9%) had malignancy and 85 (30.7%) had choledocholithiasis. Overall clinical success rate was 76.1% and was the highest in patients with biliary stones (81.2%) and lowest in those with tumors (73.5%) (p = 0.094). Procedure-related adverse events occurred in 11.9%, including post-ERCP pancreatitis in 3.6%, with a procedure-related mortality rate of 1.4%. Annual case volumes increased, and mean procedure duration decreased from 162 to 115 min (p = 0.0007) over time. A previously- rained endoscopist initially performed all cases; two staff endoscopists were trained in ERCP during the study period, performing 130 and 89 ERCPs during training, with clinical success rates of 84% and 74% during their subsequent independent practice. Conclusion: An ERCP service can be successfully developed at a rural African hospital, with acceptable success and adverse event rates. Biliary obstruction due to stones or tumors are the most common findings. While a previously trained endoscopist should initiate and champion the service, staff endoscopists can be successfully trained despite limited case volumes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: ERCP is the gold standard for pancreaticobiliary evaluation but is associated with complications. Less invasive diagnostic alternatives with similar capabilities may be cost-effective, particularly in situations involving low prevalence of disease. The aim of this study was to compare the performance of endoscopic ultrasound (EUS) with magnetic resonance cholangiopancreatography (MRCP) and ERCP in the same patients with suspected extrahepatic biliary disease. The economic outcomes of EUS-, MRCP-, and ERCP-based diagnostic strategies were evaluated. METHODS: Prospective cohort study of patients referred for ERCP with suspected biliary disease, MRCP and EUS were performed within 24 h before ERCP, The investigators were blinded to the results of the alternative imaging studies, A cost-utility analysis was performed for initial ERCP, MRCP, and EUS strategies for these patients, RESULTS: A total of 30 patients were studied, ERCP cholangiogram failed in one patient, and another patient did not complete MRCP because of claustrophobia. The final diagnoses (N = 28) were CBD stone (mean = 4 mm; range = 3-6 mm) in five patients; biliary stricture in three patients, and normal biliary tree in 20. Two patients had pancreatitis after therapeutic ERCP, one after precut sphincterotomy followed by a normal cholangiogram, EUS was more sensitive than MRCP in the detection of choledocolithiasis (80% vs 40%), with similar specificity, MRCP had a poor specificity and positive predictive value for the diagnosis of biliary stricture (76%/25%) compared to EUS (100%/ 100%), with similar sensitivity. The overall accuracy of MRCP for any abnormality was 61% (95% CI = 0,41-0.78) compared to 89% (CI = 0,72-0,98) for EUS. Among those patients with a normal biliary tree, the proportion correctly identified with each test was 95% for EUS and 65% for MRCP (p < 0,02), The cost for each strategy per patient evaluated was $1346 for ERCP, $1111 for EUS, and $1145 for MRCP, CONCLUSIONS: In this patient population with a low disease prevalence, EUS was superior to MRCP for choledocholithiasis, EUS was most useful for confirming a normal biliary tree and should be considered a low-risk alternative to ERCP, Although MRCP had the lowest procedural reimbursement, the initial EUS strategy had the greatest cost-utility by avoiding unnecessary ERCP examinations. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Cholestasis may result from diverse etiologies. We review chronic cholestatic disorders involving small intrahepatic bile ducts in the adult ambulatory care setting. Specifically, we discuss variant forms of primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) as well as other conditions that may present diagnostic and therapeutic difficulties. METHODS: We conducted a MEDLINE search of the literature (1981-1997) and reviewed the experiences at the Mayo Clinic. All articles were selected that discussed anti-mitochondrial antibody (AMA)-negative PBC, small-duct PSC (formerly pericholangitis), and idiopathic adulthood ductopenia. RESULTS: The most common chronic cholestatic liver diseases affecting adults are PBC and PSC. Patients without the hallmarks of either syndrome are diagnosed according to their clinical and histological characteristics. Autoimmune cholangitis is diagnosed if clinical and histological features are compatible with PBC but autoantibodies other than AMA are present. Isolated small duct PSC is diagnosed if patients have inflammatory bowel disease, biopsy features compatible with PSC, but a normal cholangiogram. If ductopenia (absence of interlobular bile ducts in small portal tracts) is found histologically in the absence of PSC, inflammatory bowel disease, and other specific cholestatic syndromes such as drug reaction or sarcoidosis, the most likely diagnosis is idiopathic adulthood ductopenia. CONCLUSIONS: Based on these definitions, an algorithm for diagnosis and therapy in patients with laboratory evidence of chronic cholestasis may be constructed, pending results of further investigations into the etiopathogenesis of these syndromes. [ABSTRACT FROM AUTHOR]

Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease, characterized by multiple strictures and dilatations of the intra- and extrahepatic bile ducts, leading to progressive liver fibrosis, in 10–15% cholangiocarcinoma, and ultimately end-stage liver disease. The pathogenesis is poorly understood, but (epi-)genetic factors, mechanisms of innate and adaptive immunity, toxic effects of hydrophobic bile acids, and possibly intestinal dysbiosis appear to be involved. The strong link with inflammatory bowel disease (IBD) is associated with a markedly enhanced risk of colorectal cancer which next to cholangiocarcinoma represents the most serious diagnostic challenge in long-term PSC management. Despite extensive research, no medical treatment has been proven so far to prolong the time to liver transplantation (LTx), which remains the effective treatment in late-stage disease. Recurrence of PSC after LTx is observed in up to 20% of patients. Here, we briefly summarize actual views on PSC pathogenesis and provide an algorithmic approach to diagnostic procedures and recommendations for the management of PSC and its complications. We describe promising treatment options subject to current clinical trials. [ABSTRACT FROM AUTHOR]

Patients with cholestatic liver function tests and histological features of primary sclerosing cholangitis (PSC) but without the typical cholangiographic changes are considered to have small-duct PSC. The incidence of small-duct PSC and the natural history still is not known. We performed a retrospective search for patients diagnosed with small-duct PSC between January 1997 and December 2003. The diagnosis of small-duct PSC was based on biochemical features of chronic cholestasis, liver biopsy findings consistent with PSC, and a normal cholangiogram on endoscopic retrograde cholangiography. Six patients fulfilled the diagnostic criteria for small-duct PSC. All patients received medical therapy. After a mean follow-up time of 26.0 +/- 29.8 months (range, 7-84 months), all patients are alive. Repeated liver biopsy was performed in one patient, 58 months after the initial one, and disclosed amelioration of histological findings (reduction in the Ludwig fibrosis score from 4 to 2). During follow-up symptoms disappeared in all patients who were symptomatic at diagnosis; none of those who were asymptomatic at diagnosis developed symptoms. At the time of last follow-up all patients showed significant improvement of their biochemical variables compared to baseline. Administration of aminosalicylates seemed to be of benefit irrespective of the presence of inflammatory bowel disease. No patients underwent liver transplantation or developed cholangiocarcinoma. Even though our study included a low number of patients and the follow-up time was relatively short, we can suggest that small-duct PSC rarely progresses to large-duct PSC and does not seem to be associated with development of cholangiocarcinoma. It thus seems to represent a separate entity with a favorable prognosis. [ABSTRACT FROM AUTHOR]

Introduction: Multiple gallbladders represent a rare congenital disorder, and coexistence with carcinoma is extremely rare, leading to a high possibility of misdiagnosis and surgical complications. In this study, a case was reported and the literature was reviewed. Case presentation: An 80-year-old woman was diagnosed with acute cholecystitis via ultrasonography and was successfully treated with antibiotics. After the patient's biliary colic relapsed, she was referred to our hospital. Multiple imaging modalities revealed duplication of her gallbladder (H-type) and suggested coexistence with carcinoma. According to preoperative evaluations, we assumed the patient had stage IIIA disease, and cholecystectomy, cholangiography using a near-infrared ray vision system, and sectionectomy of segments 4a and 5 were performed. Contrary to the high standardized uptake values obtained by 18F-fluoro-2-deoxy-D-glucose positron emission tomography, gallbladder carcinoma was pathologically diagnosed as stage 0 mucosal cancer. Seven days after the operation, portal thrombosis of the posterior branch was revealed, and conservative therapy was indicated; satisfactory results were achieved. The patient was discharged 65 days after surgery. No recurrence was observed for 1 year after surgery. Conclusions: An extremely rare case of malignancy in a duplicated gallbladder was reported, and the literature was reviewed. Accurate estimations are feasible for diagnoses of multiple gallbladders, where correct evaluations are vital, especially in malignant cases. Because of the possibility of malignancy, resected accessory gallbladders should be scrutinized pathologically. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the biliary tree and hepatic parenchymal findings on magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) in small-duct primary sclerosing cholangitis (SD-PSC). Methods: Thirty-nine patients with biopsy-proven primary sclerosing cholangitis (PSC) without any bile duct abnormality on MRCP (n = 15) or ERCP (n = 24) at the time of diagnosis were identified. Follow-up MRCP was available in 36/39 patients (12/15 Baseline MRCP group and 24 Baseline ERCP group). Two radiologists in consensus assessed the MRI/MRCP findings. The baseline MRI/MRCP of 15 SD-PSC patients was compared with MRI/MRCP of 15 normal healthy potential liver donors (Control group). Comparisons were made between SD-PSC patients and the Control group, and between baseline and follow-up MRI/MRCP findings in the SD-PSC patients. Results: In the 15 Baseline MRCP SD-PSC subjects, the biliary tree was normal with a trend of larger bile ducts compared to the Control group. Periductal enhancement (arterial phase: 70%, 7/10; delayed phase: 90%, 9/10), heterogeneous parenchymal signal on T2-weighted (53%, 8/15) and post contrast-enhanced images (70%, 7/10), and enlarged periportal lymph nodes (73%, 11/15) were frequently present in patients with SD-PSC. Eight (33%) of 24 SD-PSC patients who had normal MRCP at baseline MRCP or initial follow-up MRCP after normal baseline ERCP showed large-duct PSC (LD-PSC) features on follow-up and the 10-year cumulative incidence for progression to LD-PSC rate was 8.5%. Conclusion: SD-PSC patients have a normal biliary tree but frequently have peribiliary enhancement, abnormal parenchymal signal intensity, and periportal lymphadenopathy. One-third shows progression to LD-PSC on follow-up. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential tool to investigate patients with the postcholecystectomy syndrome. A normal cholangiogram usually rules out the presence of biliary tract disease, and further investigations are directed towards other organ systems. We present a case in which a normal ERCP caused a significant delay in reassessing the biliary tree in a patient who eventually presented with choledocholithiasis. A repeat ERCP should be considered in patients with persistent biliary tract pain, even if the initial ERCP shows no abnormality. [ABSTRACT FROM AUTHOR]

Objectives and study: Various degrees of biliary changes are considered to be part of the histological picture of children with pediatrics autoimmune liver disease (AILD), but the literature is scarce and confusing. We aimed to describe the characteristics of children with AILD (autoimmune hepatitis, AIH, and autoimmune sclerosing cholangitis, ASC) focusing on the prevalence and type of biliary abnormalities on initial biopsy to see whether ASC was predictable on histological ground. Methods: The files of children diagnosed with AILD were reviewed. The Ishak score was used to grade inflammation and fibrosis on biopsy; a biliary score was built to grade bile duct injury. Demographic, laboratory and histological features at diagnosis were reported and compared between the two groups (AIH vs ASC). Results: Forty-one patients were diagnosed with AIH (n = 24), ASC (n = 13) and PSC (n = 4) between 2009 and 2018. Twenty-nine patients [F = 76%, AIH = 20, ASC = 9, median age at diagnosis 11.7 (range 2.2–17.8)] were included in the study; 12 (4 with PSC) were excluded. Prevalence of inflammatory bowel disease was higher in ASC group (56% vs 10% in AIH, p < 0.05). On histology 17% had cirrhosis. The grade of biliopathy with AILD was moderate in 72% and severe in 31%, and overall more prominent in ASC (p = 0.031). The inflammation of the bile ducts was classified as "multifocal" or "diffuse" mainly in ASC patients (89% vs 45% in AIH, p = 0.043). Periductular fibrosis was reported in 52% of AILD patients, with a higher mean score in ASC group (p < 0.05). However, ductular reaction, biliary metaplasia and granulomatous cholangitis were equally reported in AIH and ASC, providing no clear-cut for the distinction of the two entities in the global histological evaluation. Conclusions: Majority of patients with pediatrics AILD have "moderate" or "severe" features of biliopathy; AIH and ASC are not easily distinguishable on histological ground at diagnosis, and therefore, the cholangiogram remains the only effective tool to differentiate patients with AIH from those with ASC. Further prospective studies are needed to better define histological biliary features in AILD, assess if the biliopathy responds to immunosuppressive treatment and evaluate its impact on long-term outcome. [ABSTRACT FROM AUTHOR]

Introduction: Biliary strictures are a common complication among donation after cardiac death (DCD) liver transplantation (LT) recipients and may require multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures. We evaluated the risk factors associated with development of biliary strictures in DCD LT recipients.Methods: DCD LT recipients who underwent transplantation from 2012 to 2017 were divided into 2 groups: (a) those with anastomotic or non-anastomotic biliary strictures who required ERCP ("stricture group") and (b) those who did not require ERCP or had cholangiograms without evidence of biliary strictures ("non-stricture group"). Clinical data, cholangiograms and laboratory values at day 0 and day 7 after LT were compared between the two groups.Results: Forty-nine of the 100 DCD LT recipients underwent ERCP. Thirty-four of these 49 LT recipients had evidence of anastomotic or non-anastomotic biliary strictures (stricture group), while the remaining 66 LT recipients comprised the non-stricture group. Donor age was significantly higher in stricture group compared to non-stricture group (49.2 ± 1.8 vs 42.8 ± 1.57 years, respectively; p = 0.01). The stricture group had a significantly higher total bilirubin at day 0 (3.5 ± 0.37 vs 2.6 ± 0.21 mg/dL; p = 0.02) and INR at day 7 (1.24 ± 0.06 vs 1.13 ± 0.01; p = 0.048) compared to the non-stricture group. Multi-variate analysis demonstrated significant association between biliary strictures and total bilirubin at day 0 of LT and age of donor.Conclusion: Biliary strictures occur frequently in DCD LT recipients and may be associated with older age of donor. Hyperbilirubinemia immediately after transplant and higher INR in the first 7 days after transplant may predict subsequent development of biliary strictures. [ABSTRACT FROM AUTHOR]

Autoimmune biliary diseases are poorly understood but important to recognize. Initially, autoimmune biliary diseases are asymptomatic but may lead to progressive cholestasis with associated ductopenia, portal hypertension, cirrhosis, and eventually liver failure. The three main forms of autoimmune biliary disease are primary biliary cirrhosis, primary sclerosing cholangitis, and IgG4-associated cholangitis. Although some overlap may occur between the three main autoimmune diseases of the bile ducts, each disease typically affects a distinct demographic group and requires a disease-specific diagnostic workup. For all the autoimmune biliary diseases, imaging provides a means to monitor disease progression, assess for complications, and screen for the development of hepatobiliary malignancies that are known to affect patients with these diseases. Imaging is also useful to suggest or corroborate the diagnosis of primary sclerosing cholangitis and IgG4-associated cholangitis. We review the current literature and emphasize radiological findings and considerations for these autoimmune diseases of the bile ducts. [ABSTRACT FROM AUTHOR]

Objectives: To assess the value of variable flip angle-based T1 liver mapping on gadoxetate disodium-enhanced MRI in patients with primary sclerosing cholangitis (PSC) for evaluation of global and segmental liver function, and determine a possible correlation with disease severity.Methods: Sixty-one patients (19 female, 42 male; mean age 41 years) with PSC were included in this prospective study. T1 mapping was performed using a 3D-spoiled GRE sequence (flip angles 5°, 15°, 20°, 30°) before, 16 (HP1) and 132 min (HP2) after contrast injection. T1 values were measured and compared (Wilcoxon-Test) by placing ROIs in each liver segment. The mean reduction of T1 relaxation time at HP1 and HP2 was calculated and correlated with liver function tests (LFTs), MELD, Mayo Risk and Amsterdam Scores (Spearman correlation).Results: Significant changes of T1 relaxation times between non-enhanced and gadoxetate disodium-enhanced MRI at HP1 and HP2 could be observed in all liver segments (p < 0.0001). A significant correlation of T1 reduction could be observed with LFTs, MELD and Mayo Risk Score (p < 0.05).Conclusions: T1 mapping of the liver using a variable flip angle-based sequence is a feasible technique to evaluate liver function on a global level, and may be extrapolated on a segmental level in patients with PSC.Key Points: • T1 mapping enables evaluation of global liver function in PSC. • T1 relaxation time reduction correlates with the MELD and MayoRisk Score. • Extrapolated, T1 mapping may allow for segmental evaluation of liver function. [ABSTRACT FROM AUTHOR]

The article presents abstracts of studies related to gastroenterology including a comparison of accuracy of endoscopic ultrasound and magnetic resonance cholangiopancreatography in the diagnosis of choledocholithiasis, the normalization of serum alkaline phosphatase as a biomarker of decreased major adverse event risk in primary sclerosing cholangitis, and the prevalence of non-alcoholic fatty pancreas disease as well as its risk factors.

This series of obstetric-related trauma represents only a small proportion (15%) of patients. The management of rectovaginal fistulae was largely dictated by the underlying aetiology with surgical intervention offering a potential cure in the majority. This often necessitated colonic defunctioning and subsequent repair in a staged procedure. Complete resolution with minimal morbidity may be achieved in 77% of these cases. [ABSTRACT FROM AUTHOR]

Contrast-enhanced magnetic resonance imaging and magnetic resonance cholangiopancreatography (MRCP), due to their excellent soft tissue contrasts, have become first-line noninvasive tests in the characterization and detection of both hepatic and pancreaticobiliary pathologies. MRCP is also helpful in detecting the level and cause of obstruction in patients presenting with jaundice. Cholangiocarcinoma (CCA) is the most common primary malignant tumor arising from the bile duct epithelium, with extrahepatic tumors presenting more often than with intrahepatic ones. However, the diagnosis and management of CCA is made more complex by a variety of malignant and benign conditions that resemble CCA, including hepatocellular carcinoma variants such as the fibrolamellar variant of hepatocellular carcinoma, cholangiocellular carcinoma, biliary metastases, hepatic inflammatory pseudotumor, lymphoepithelioma-like carcinoma, confluent fibrosis, primary sclerosis cholangitis, and the secondary sclerosing cholangitis complex. Consequently, knowledge of the underlying risk factors and imaging characteristics of these conditions is important in differentiating between neoplastic and non-neoplastic conditions in order to reach a definite diagnosis. Endoscopic retrograde cholangiopancreatography should be reserved for those patients who require intervention or biopsy for histopathological diagnosis. [ABSTRACT FROM AUTHOR]

The article presents abstracts on surgery topics which include Sleeve Gastrectomy in Type ll Diabetic Obese Patients, Treatment by Gastric Bypass for Type ll Diabetes Mellitus and Associated Co-morbidities and Diabetes Remission Rates after Bariatric Surgery.

Background: Fully covered self-expandable metal stents (FCSEMS) have been used as a rescue therapy for several benign biliary tract conditions (BBC). Long-term stent placement commonly occurs, and prolonged FCSEMS placement is associated with the majority of the complications reported. This study evaluated the duration of stenting and the efficacy and safety of temporary FCSEMS placement for three BBCs: refractory biliary leaks, postsphincterotomy bleeding, and perforations. Methods: This was a retrospective case series with long-term follow-up of 25 patients who underwent FCSEMS placement for BBCs. This study included 17 patients with postcholecystectomy refractory biliary leaks who had previously undergone unsuccessful sphincterotomy and plastic stent placement, 4 patients with difficult-to-control postsphincterotomy bleeding, and 4 patients with a perforation following endoscopic sphincterotomy. Stents were removed according to clinical evidence of problem resolution. The review included stenting duration, safe FCSEMS removal, clinical efficacy, complications, and long-term outcomes. During the follow-up period, ERCP and cholangioscopy procedures were performed to exclude the possibility of bile duct lesion development. Results: Complete resolution of the initial condition was achieved in all patients. Patients with biliary leaks had a median stent duration time of 16 days (range 7-28 days). Patients with bleeding had stents removed after a median time of 6 days (range 3-15 days). Patients with perforations had their stents removed after a median time of 29.5 days (range 21-30 days). There were no complications related to stenting. Conclusions: Temporary placement of a FCSEMS for 30 days or less is an effective rescue therapy for refractory biliary leaks, difficult-to-control post-endoscopic sphincterotomy bleeding, and perforations. Duration of stenting should be different for each type of condition. Stents can be safely removed, and short-term stenting is associated with the absence of early and late complications. [ABSTRACT FROM AUTHOR]

OBJECTIVES:American Association for the Study of Liver Diseases (AASLD) guidance recommends measurement of IgG4 in patients with sclerosing cholangitis (SC). The objective of this study was to evaluate this by analyzing our SC practice.METHODS:Characteristics were collected on 168 patients with radiological or biopsy proven SC; IgG4 was measured and magnetic resonance cholangiopancreatography studies were reviewed.RESULTS:In all, 49% of patients were females and 55% had inflammatory bowel disease. Large duct disease was present in 63%, small duct disease in 8%, overlap with AIH in 11%, and secondary SC in 18%. Secondary etiologies included autoimmune pancreatitis (AIP) (8%), intra-hepatic cholelithiasis (3%), portal vein thrombosis (2%), and neonatal Kasai (2%). In all, 101 patients had sufficient radiology and serology for re-evaluation. IgG4 was elevated (>104 mg/dl) in 22% of patients. This was associated with male gender (73%; P=0.016), a past history of pancreatitis (27% vs. 5%; P=0.007), a higher alkaline phosphatase (ALP) value, median 338.5 U/l vs. 160 (P=0.005), and a higher primary sclerosing cholangitis (PSC) Mayo risk score, mean 0.6 vs. −0.2 (P=0.0008). Prior biliary intervention was more likely (36 vs. 13%; P=0.023), while abnormal pancreatic imaging was noted in 15%, more frequently if IgG4 was elevated (40 vs. 8%; P=0.0007). After excluding those with pancreatic disease on magnetic resonance imaging, 14 patients had elevated IgG4. This group had higher ALP 379 U/l vs. 155.5 (P=0.0006), aspartate aminotransferase (AST) 72.5 U/l vs. 34 (P=0.0005), alanine aminotransferase (ALT) 90.5 U/l vs. 36 (P=0.004), and PSC Mayo risk score values 0.4 vs. −0.2 (P=0.017).CONCLUSIONS:SC is a heterogeneous liver injury. IgG4 testing may be clinically important in all patients, since it appears to identify a distinct patient population, more so than just those with AIP. [ABSTRACT FROM AUTHOR]

BACKGROUND: Even with standardization and increasing experience, laparoscopic cholecystectomy still entails the risk of injury to the bile ducts. The incidence of iatrogenic bile-duct injury is currently estimated at 0.3-0.9%. In spite of the downward trend compared to the historical course, the incidence of iatrogenic bile duct injuries is still higher and so continues to be a determining factor for morbidity with LCHE. METHODS AND RESULTS: Independent of the frequency, the nature of bile duct lesions has also changed. There are not only direct injuries, similar to the direct transection of the bile duct with open LCHE, but there are also long substance defects due to resection of the hepatic duct up to or beyond the bifurcation. In one-quarter of cases, neighboring vascular structures are also injured. With inadequate treatment, the life quality suffers due to functional long-term damage reflected in cholangitis or secondary biliary cirrhosis with portal hypertension up to loss of liver function. CONCLUSIONS: Corrective surgery requires suitable surgical expertise in hepatobiliary surgery as well as institutional resources that allow an individual treatment plan based on interdisciplinary cooperation among surgeon, interventional radiologist and gastroenterologist. The long-term prognosis will depend on early diagnosis and efficient therapeutic management. [ABSTRACT FROM AUTHOR]

Background: Intraductal ultrasonography (IDUS) is a useful procedure for diagnosing microlithiasis in the bile duct but it is not easy to differentiate between tiny echogenicity and real microlithiasis. We compared the echogenicity seen on IDUS and the findings of bile microscopy (BM) of bile that was collected in the common bile duct (CBD) to determine whether the echogenicity seen on IDUS is real microlithiasis.Methods: This prospective study involved a total of 30 patients who experienced biliary pain (n = 11), acute cholecystitis (n = 11) or indeterminate pancreatitis (n = 8) without a filling defect or obstruction in the bile duct. IDUS was performed during endoscopic retrograde cholangiopancreatography (ERCP), followed by bile aspiration for BM. Endoscopic sphincterotomy (EST) was performed if definite echogenic materials were observed on IDUS.Results: Of the 30 patients, 23 (77%) had echogenic materials visible in the CBD on IDUS. Of these 23 patients, 13 (57%) were found to have biliary crystals by BM. The size of the echogenic materials was the only significant factor associated with BM positivity. Using the receiver operating curve, the optimal size of the echogenicity to differentiate real microlithiasis was 1.4 mm.Conclusions: Optimal concordance between IDUS and BM was observed when the size of the microlithiasis was greater than 1.4 mm; under these conditions the sensitivity and specificity were 71% and 75%, respectively. This information may be useful when deciding whether to perform endoscopic sphincterotomy. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics which include a study for in-hospital and out-hospital treatments and outcomes of patients having acute ischemic colitis, a research that determines the symptoms and pathophysiologic abnormalities of fecal incontinence, and a case study on ranitidine associated to hepatotoxicity.

The article presents abstracts on medical topics related to pancreatic cysts which include "Duodenal Duplication Cysts: A Rare, But Treatable Cause of Relapsing Pancreatitis," by Shayan Irani and colleagues, "Successful Endoscopic Therapy of Traumatic Bile Leaks: Report of Fourteen Cases," by Matthew Spinn and colleagues, and "Observations on Acute Pancreatitis in the Pediatric Patients," by Vishal Jain and colleagues.

The article presents abstracts on topics related to esophagus including the "Circumferential Inlet Patch with an Esophageal Ring," by James Kwiatt and colleagues, "Ranitidine-induced Hepatitis: A Rare Cause of Hepatotoxicity," by Tae Lee and colleagues, and "Esophageal Adenocarcinoma Leading to Leptomeningeal Carcinomatosis," by Prakash Viswanathan and colleagues.

The article presents abstracts of studies related to gastrointestinal surgery including "Laparoscopic Versus Open Incisional Hernia Repair," "Ventral Hernia a Repair: Cost-Benefit Study," and "Surgery for Recurrent Groin Hernia: A Swedish Hernia Register Study."

Although intraoperative cholangiography (IOC) is a widely used method for detecting common bile duct stones (CBDS), its accuracy has not been fully evaluated in large nonselected patient samples. The purpose of this study was to assess the sensitivity, specificity and predictive value of dynamic IOC regarding its ability to diagnose CBDS in a population-based setting, and to assess the morbidity associated with the investigation. All patients operated on for gallstone disease between 2003 and 2005 in the county of Uppsala in Sweden, a county with a population of 302,000 in December 2004, were registered prospectively. The outcome of cholangiography was validated against the postoperative clinical course. 1171 patients were registered, and among these IOC was performed in 1117 patients (95%). Common bile duct stones were found in 134 patients (11%). One perforation of the common bile duct caused by the IOC catheter was recorded. Sensitivity was 97%, specificity 99%, negative predictive value 99%, positive predictive value 95%, and overall accuracy 99%. In 7 of the 134 cases where IOC indicated CBDS, no stones could be verified on exploration. In 4 of the 979 cases where IOC was normal, the clinical course indicated overlooked CBDS. Intraoperative cholangiography is a safe and accurate method for detecting common bile duct stones. [ABSTRACT FROM AUTHOR]

As suggested by observational and animal studies, heparin has antiinflammatory effects that could prevent acute post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Low-molecular-weight heparin did not reduce the incidence of post-ERCP pancreatitis in a controlled study. The current study aimed to determine whether prophylactic administration of low-dose unfractionated heparin, which has potentially more antiinflammatory capability, can prevent acute post-ERCP pancreatitis. Patients scheduled for ERCP in the authors’ department were randomized to receive unfractionated heparin (5,000 IU) or placebo (saline solution 0.5 ml) administered subcutaneously 20 to 30 min before the ERCP. Patients who had undergone endoscopic sphincterotomy in the past were excluded from the study. Post-ERCP pancreatitis was defined according to criteria established by Cotton: abdominal pain combined with a threefold elevation of blood amylase 24 h after the ERCP. The study enrolled 106 patients. One patient was excluded from the analysis due to inaccessible papilla of Vater, leaving 51 patients in the heparin group and 54 in the placebo group, for a total of 105 patients (62 women and 43 men) with a mean age of 64.6 years. The rate of post-ERCP pancreatitis was not different between the groups (heparin, 4 patients, 7.8%; placebo, 4 patients, 7.4%). Two patients in each group experienced mild bleeding. The study did not demonstrate a significant effect of low-dose unfractionated heparin in the prevention of post-ERCP pancreatitis. A multicenter trial with a larger number of patients is needed to demonstrate a benefit from this drug. [ABSTRACT FROM AUTHOR]

Even when histologic findings are highly suggestive of primary sclerosing cholangitis (PSC), cholangiographic correlation is required for the diagnosis. The present gold standard, endoscopic retrograde cholangiopancreatography (ERCP), is invasive and associated with complications. To evaluate the usefulness of magnetic resonance cholangiopancreatography (MRCP) in diagnosing PSC in children. MRCP studies were retrospectively reviewed in 20 children with clinical suspicion of PSC and who had undergone liver biopsy. MRCP studies were considered positive or negative for PSC depending on the presence or absence of dilatation, irregularity, multifocal strictures and beading of the bile ducts. Twenty children (14 boys, 6 girls) with an average age of 13 years qualified for the study. Of 19 diagnostic MRCP studies, 16 were called positive and 3 were called negative. An overall diagnosis of PSC-positive was assigned to all 19 patients based on clinical and laboratory findings, biopsy results and cholangiographic data. Based on this overall diagnosis, MRCP was 84% sensitive and accurate to diagnose PSC in children. MRCP can be a valuable tool in diagnosing pediatric PSC that can demonstrate major intra- and extrahepatic ducts in most cases. An unequivocally positive MRCP study should not be followed by ERCP for diagnosing PSC in children. [ABSTRACT FROM AUTHOR]

In patients with suspected pancreatico-biliary disease, endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for those requiring therapeutic intervention. However, difficulty arises in identifying patients likely to require therapy in the early phase of diagnostic work-up. An algorithm has been developed by the authors based upon prospective assessment of ERCP patients for triage of patients to magnetic resonance cholangiopancreatography (MRCP) or ERCP with suspected pancreatico-biliary disease. We aimed to validate this algorithm in an independent group of patients using a different group of endoscopists blinded to the algorithm. Patients were stratified into different categories by clinical, ultrasound and liver function test findings. The algorithm stratified patients by the likelihood of therapeutic intervention. The accuracy of the algorithm for a therapeutic outcome was assessed by receiver operator characteristics (ROC) curve analysis. Hundred and twenty-five consecutive patients (Oct 2005 to July 2006) were prospectively assessed by MRCP or ERCP according to the algorithm, and the outcomes recorded. Fifty-seven patients were triaged to MRCP and 63 patients were triaged to ERCP. A category was not assessable in five patients. Three patients from the MRCP group required subsequent therapeutic ERCP. Diagnostic ERCP was performed in three patients in the ERCP group. ERCP-related complications occurred in four patients. The algorithm performed well in predicting the requirement for intervention as determined by the area under the ROC curve [0.84 (95%CI 0.76–0.92)]. Our study confirms that an algorithm-based approach can reproducibly predict those patients requiring therapeutic biliary intervention. [ABSTRACT FROM AUTHOR]

The article presents abstracts on functional bowel disorders which include a study on the risks of intestinal bacterial overgrowth (IBO) in patients with irritable bowel syndrome (IBS), research on side effects of receptor tegaserod (Zelnorm), and a review on the use of probiotics in IBS treatment.

The article presents abstracts on medical endoscopy which include the evaluation of colonoscopy performance, a study on pancreatic abscess treatment using endoscopic necrosectomy and a methodology for colon decompression during colonoscopy.

The article presents abstracts on medical topics which include the effect of Tegaserod on gastric accommodation and emptying in patients, a case report on eosinophilic gastritis and the risks factors in patients with bleeding peptic ulcers.

The article presents abstracts on medical topics which include the medical characteristics of malignant biliary obstruction, a study on prognostic factors in advanced cholangiocarcinoma and the effectiveness of magnetic resonance cholangiopancreatography in pancreaticobiliary disease diagnosis.

The article presents abstracts on medical topics which include a case on incomplete colonoscopy, the treatment of symptomatic small intestinal bacterial overgrowth after gastric bypass surgery and celiac disease in the adult community.

The article presents abstracts on medical topics which include a case report on hepatic neuro-endocrine tumor, the role of liver transplantation in neurological appearance of Wilson's Disease and the risk of analgesics in Cirrhosis.