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Biliary Obstruction (biliary + obstruction)
Kinds of Biliary Obstruction Selected AbstractsBILIARY STENTING FOR MALIGNANT BILIARY OBSTRUCTIONDIGESTIVE ENDOSCOPY, Issue 1 2006Toshio Tsuyuguchi Management of patients with malignant biliary obstruction remains controversial. We reviewed our current status of biliary stenting for malignancy. The initial step in our management is endoscopic nasobiliary drainage, which is used not only for preoperative drainage but also to decide whether or not surgery is appropriate treatment. Although a metal stent has a longer patency time than a plastic stent, it costs up to thirty-fold more than the latter in Japan. Therefore, stent selection, metal or plastic, should be dependent on the expected prognosis of each patient with malignant biliary strictures. In the present paper, we also discuss the efficacy of the covered metal stent and stenting for malignant hilar obstruction. [source] Discussant's Comment: Endoscopic Stenting for Malignant Biliary ObstructionDIGESTIVE ENDOSCOPY, Issue 2000Yoshitsugu Kubota No abstract is available for this article. [source] Expandable metal stents in chronic pancreatitisHPB, Issue 1 2003JJ French Background Biliary obstruction in chronic pancreatitis may be relieved by the insertion of a biliary endoprosthesis. Stenting is usually achieved with a plastic device, but self-expandable metal stents may also be used. Case outlines Two patients are described with severe chronic pancreatitis complicated by biliary obstruction and portal vein thrombosis, who underwent insertion of metallic biliary endoprostheses. In both patients the endoprostheses became occluded, at 12 and 7 months respectively, which necessitated open operation. Both patients experienced surgical complications and one patient died postoperatively. Discussion The use of metal endoprostheses in chronic pancreatitis may result in occlusion, necessitating open operation. Such stents should be used with caution in these patients, who are likely to be high-risk surgical candidates. [source] Structural and mechanical remodelling of the common bile duct after obstructionNEUROGASTROENTEROLOGY & MOTILITY, Issue 2 2002B. U. DUCH Biliary obstruction in man, most often caused by cholelithiasis, induces remodelling of the bile ducts. Obstruction-induced structural remodelling of the common bile duct (CBD) has been previously described. The mechanical changes that accompany the structural remodelling, however, have not been studied in detail. The aim of this study is to quantify the structural and mechanical changes in the CBD at different time intervals after acute obstruction. The CBD was ligated in the pig, near the duodenum, and studied after 3 h, 12 h, 2 days, 8 days and 32 days (n=5 in each group). One additional animal in each group was sham-operated. At each scheduled time, the CBD was mechanically tested in vitro with a computer-controlled volume infusion system to study the pressure,volume relationship of the CBD segment. A video camera provided simultaneous measurements of the outer dimensions of the CBD at the various pressures. The diameter and wall thickness of the CBD increased about three-fold in the 32-day group compared to the sham group (P < 0.001). The circumferential stress,strain relationship differed between groups (P < 0.001); it was shifted to the right, indicating softening, in the 3-h, 12-h, and 2-day groups and to the left, indicating stiffening, in the 8-day and 32-day group, compared to the sham group. The longitudinal stress,strain curves were all shifted to the left of the circumferential stress,strain curves (P < 0.05). The collagen area increased during obstruction (P < 0.001) but no correlation between the size of the collagen area and the biomechanical parameters was found. A practical implication of the present study serves as a warning to surgeons. A reduction in the wall stiffness in the first several days of obstruction along with an increased duct diameter and a decreased wall thickness suggest that operative procedures such as suturing, anastomosis and procedures related to ERCP must be performed with special care to avoid damage to the CBD. [source] ENDOSONOGRAPHY-GUIDED GALLBLADDER DRAINAGE FOR ACUTE CHOLECYSTITIS FOLLOWING COVERED METAL STENT DEPLOYMENTDIGESTIVE ENDOSCOPY, Issue 1 2009Osamu Takasawa Endosonography-guided biliary drainage (ESBD) is gaining acceptance as an effective treatment for obstructive jaundice. Only a few reports on the application of this technique to the gallbladder (endosonography-guided gallbladder drainage [ESGBD]) have been published in the literature. In order to relieve acute cholecystitis which developed in a patient with unresectable malignant biliary obstruction after deployment of a covered metal stent (CMS), we applied this technique. ESGBD was carried out by using an electronic curved linear array echoendoscope. After visualization of the gallbladder and determination of the puncture route, a needle knife papillotome was advanced with electrocautery to pierce the gastric and gallbladder walls. Under the guidance of a guidewire inserted through the needle sheath into the gallbladder, a 7.2 Fr, 30 cm-long, single pigtail plastic tube was placed to bridge the gallbladder and the stomach. No complications relevant to the procedure were encountered. ESGBD was quite effective in ameliorating the patient's acute cholecystitis and the drainage tube was removed after 10 days without sequelae. Acute cholecystitis following CMS deployment is considered to be a good indication for ESGBD. [source] BILIARY STENTING FOR MALIGNANT BILIARY OBSTRUCTIONDIGESTIVE ENDOSCOPY, Issue 1 2006Toshio Tsuyuguchi Management of patients with malignant biliary obstruction remains controversial. We reviewed our current status of biliary stenting for malignancy. The initial step in our management is endoscopic nasobiliary drainage, which is used not only for preoperative drainage but also to decide whether or not surgery is appropriate treatment. Although a metal stent has a longer patency time than a plastic stent, it costs up to thirty-fold more than the latter in Japan. Therefore, stent selection, metal or plastic, should be dependent on the expected prognosis of each patient with malignant biliary strictures. In the present paper, we also discuss the efficacy of the covered metal stent and stenting for malignant hilar obstruction. [source] Microbial biofilms associated with biliary stent cloggingFEMS IMMUNOLOGY & MEDICAL MICROBIOLOGY, Issue 3 2010Emilio Guaglianone Abstract Endoscopic stenting is a palliative approach for the treatment of diseases involving biliary obstruction. Its major limitation is represented by stent occlusion, followed by life-threatening cholangitis, often requiring stent removal and replacement. Although it has been suggested that microbial colonization of biliary stents could play a role in the clogging process, the so far available data, particularly on the role of anaerobic bacteria, are not enough for a comprehensive description of this phenomenon. Our study was focused on the analysis of 28 explanted biliary stents by culturing, denaturing gradient gel electrophoresis and scanning electron microscopy to identify all the aerobic/anaerobic bacteria and fungi involved in the colonization of devices and to verify the ability of isolated anaerobic bacterial strains to form a biofilm in order to better understand the mechanisms of stent clogging. [source] Peptide antibiotic human beta-defensin-1 and ,2 contribute to antimicrobial defense of the intrahepatic biliary treeHEPATOLOGY, Issue 4 2004Kenichi Harada Human beta-defensins (hBDs) are important antimicrobial peptides that contribute to innate immunity at mucosal surfaces. This study was undertaken to investigate the expression of hBD-1 and hBD-2 in intrahepatic biliary epithelial cells in specimens of human liver, and 4 cultured cell lines (2 consisting of biliary epithelial cells and 2 cholangiocarcinoma cells). In addition, hBD-1 and hBD-2 were assayed in specimens of bile. hBD-1 was nonspecifically expressed immunohistochemically in intrahepatic biliary epithelium and hepatocytes in all patients studied, but expression of hBD-2 was restricted to large intrahepatic bile ducts in 8 of 10 patients with extrahepatic biliary obstruction (EBO), 7 of 11 with hepatolithiasis, 1 of 6 with primary biliary cirrhosis (PBC), 1 of 5 with primary sclerosing cholangitis (PSC), 0 of 6 with chronic hepatitis C (CH-C), and 0 of 11 with normal hepatic histology. hBD-2 expression was evident in bile ducts exhibiting active inflammation. Serum C reactive protein levels correlated with biliary epithelial expression of hBD-2. Real-time PCR revealed that in all of 28 specimens of fresh liver, including specimens from patients with hepatolithiasis, PBC, PSC, CH-C and normal hepatic histology, hBD-1 messenger RNA was consistently expressed, whereas hBD-2 messenger RNA was selectively expressed in biliary epithelium of patients with hepatolithiasis. Immunobloting analysis revealed hBD-2 protein in bile in 1 of 3 patients with PSC, 1 of 3 with PBC, and each of 6 with hepatolithiasis; in contrast, hBD-1 was detectable in all bile samples examined. Four cultured biliary epithelial cell lines consistently expressed hBD-1; in contrast these cell lines did not express hBD-2 spontaneously but were induced to express hBD-2 by treatment with Eschericia coli, lipopolysaccharide, interleukin-1, or tumor necrosis factor-,. In conclusion, these findings suggest that in the intrahepatic biliary tree, hBD-2 is expressed in response to local infection and/or active inflammation, whereas hBD-1 may constitute a preexisting component of the biliary antimicrobial defense system. Supplementary material for this article can be found on the Hepatology website (http:/interscience.wley.com/jpages/0270,9139/suppmat/index.html). (Hepatology 2004;40:925-932). [source] Nonoperative imaging techniques in suspected biliary tract obstructionHPB, Issue 6 2006Frances Tse Abstract Evaluation of suspected biliary tract obstruction is a common clinical problem. Clinical data such as history, physical examination, and laboratory tests can accurately identify up to 90% of patients whose jaundice is caused by extrahepatic obstruction. However, complete assessment of extrahepatic obstruction often requires the use of various imaging modalities to confirm the presence, level, and cause of obstruction, and to aid in treatment plan. In the present summary, the literature on competing technologies including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiopancreatography (PTC), endoscopic ultrasound (EUS), intraductal ultrasonography (IDUS), magnetic resonance cholangiopancreatography (MRCP), helical CT (hCT) and helical CT cholangiography (hCTC) with regards to diagnostic performance characteristics, technical success, safety, and cost-effectiveness is reviewed. Patients with obstructive jaundice secondary to choledocholithiasis or pancreaticobiliary malignancies are the primary focus of this review. Algorithms for the management of suspected obstructive jaundice are put forward based on current evidence. Published data suggest an increasing role for EUS and other noninvasive imaging techniques such as MRCP, and hCT following an initial transabdominal ultrasound in the assessment of patients with suspected biliary obstruction to select candidates for surgery or therapeutic ERCP. The management of patients with a suspected pancreaticobiliary condition ultimately is dependent on local expertise, availability, cost, and the multidisciplinary collaboration between radiologists, surgeons, and gastroenterologists. [source] Hilar cholangiocarcinoma: diagnosis and stagingHPB, Issue 4 2005William Jarnagin Cancer arising from the proximal biliary tree, or hilar cholangiocarcinoma, remains a difficult clinical problem. Significant experience with these uncommon tumors has been limited to a small number of centers, which has greatly hindered progress. Complete resection of hilar cholangiocarcinoma is the most effective and only potentially curative therapy, and it now clear that concomitant hepatic resection is required in most cases. Simply stated, long-term survival is generally possible only with an en bloc resection of the liver with the extrahepatic biliary apparatus, leaving behind a well perfused liver remnant with adequate biliary-enteric drainage. Preoperative imaging studies should aim to assess this possibility and must evaluate a number of tumor-related factors that influence resectability. Advances in imaging technology have improved patient selection, but a large proportion of patients are found to have unresectable disease only at the time of exploration. Staging laparoscopy and 13fluoro-deoxyglucose positron emission tomography (FDG-PET) may help to identify some patients with advanced disease; however, local tumor extent, an equally critical determinant of resectability, may be underestimated on preoperative studies. This paper reviews issues pertaining to diagnosis and preoperative evaluation of patients with hilar biliary obstruction. Knowledge of the imaging features of hilar tumors, particularly as they pertain to resectability, is of obvious importance for clinicians managing these patients. [source] Indications for non-transplant surgery in primary sclerosing cholangitisHPB, Issue 4 2005Bastian Domajnko Abstract Primary sclerosing cholangitis (PCS) is a progressive disease leading to secondary biliary cirrhosis. Patients are at increased risk of developing cholangiocarcinoma, which is usually diagnosed at an advanced stage. Treatment of PCS includes medical therapy, endoscopic biliary dilation, percutaneous transhepatic stenting, extrahepatic biliary resection and liver transplantation. The most effective management of primary sclerosing cholangitis before the onset of cirrhosis remains unclear. Non-transplant surgical procedures have a limited but defined role in patients with PCS. Resection of the extrahepatic biliary tree in symptomatic non-cirrhotic patients improves hyperbilirubinaemia and prolongs both transplant-free and overall survival when compared with non-operative dilation and/or stenting. Surgical resection may also definitively establish or exclude a diagnosis of cholangiocarcinoma in patients with dominant extrahepatic or perihilar strictures. Extrahepatic bile duct resection may also reduce the risk of cholangiocarcinoma. Extrahepatic biliary resection should be considered in selected non-cirrhotic patients with symptomatic biliary obstruction and dominant extrahepatic and/or perihilar strictures. Those patients in whom cholangiocarcinoma is suspected should also undergo resection. [source] Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinomaHPB, Issue 1 2004R Andersson Background Cancer of the pancreas is a common disease, but the large majority of patients have tumours that are irresectable at the time of diagnosis. Moreover, patients whose tumours are clearly beyond surgical cure are best treated non-operatively, if possible, by relief of biliary obstruction and percutaneous biopsy to confirm the diagnosis and then consideration of oncological treatment, notably chemotherapy. These facts underline the importance of a standard protocol for the preoperative determination of operability (is it worth operating?) and resectability (is there a chance that the tumour can be removed?). Recent years have seen the advent of many new techniques, both radiological and endoscopic, for the diagnosis and staging of pancreatic cancer. It would be impracticable in time and cost to submit every patient to every test. This review will evaluate the available techniques and offer a possible algorithm for use in routine clinical practice. Discussion In deciding whether to operate with a view to resecting a pancreatic cancer, the surgeon must take into account factors related to the patient, the tumour and the institution and team entrusted with the patient's care. Patient-related factors include age, general health, pain and the presence or absence of malnutrition and an acute phase inflammatory response. Tumour-related factors include tumour size and evidence of spread, whether to adjacent organs (notably major blood vessels) or further afield. Hospital-related factors chiefly concern the volume of pancreatic cancer treated and thus the experience of the whole team. Determination of resectability is heavily dependent upon detailed imaging. Nowadays conventional ultrasonography can be supplemented by endoscopic, laparoscopic and intra-operative techniques. Computed tomography (CT) remains the single most useful staging modality, but MRI continues to improve. PET scanning may demonstrate unsuspected metastases and likewise laparoscopy. Diagnostic cholangiography can be performed more easily by MR techniques than by endoscopy, but ERCP is still valuable for preoperative biliary decompression in appropriate patients. The role of angiography has declined. Percutaneous biopsy and peritoneal cytology are not usually required in patients with an apparently resectable tumour. The prognostic value of tumour marker levels and bone marrow biopsy is yet to be established. Preoperative chemotherapy or chemoradiation may have a role in down-staging an irresectable tumour sufficiently to render it resectable. Selective use of diagnostic laparoscopy staging is potentially helpful in determination of resectability. Laparotomy remains the definitive method for determining the resectability of pancreatic cancer, with or without portal vein resection, and should be undertaken in suitable patients without clear-cut evidence of irresectability. [source] Expandable metal stents in chronic pancreatitisHPB, Issue 1 2003JJ French Background Biliary obstruction in chronic pancreatitis may be relieved by the insertion of a biliary endoprosthesis. Stenting is usually achieved with a plastic device, but self-expandable metal stents may also be used. Case outlines Two patients are described with severe chronic pancreatitis complicated by biliary obstruction and portal vein thrombosis, who underwent insertion of metallic biliary endoprostheses. In both patients the endoprostheses became occluded, at 12 and 7 months respectively, which necessitated open operation. Both patients experienced surgical complications and one patient died postoperatively. Discussion The use of metal endoprostheses in chronic pancreatitis may result in occlusion, necessitating open operation. Such stents should be used with caution in these patients, who are likely to be high-risk surgical candidates. [source] Ursodeoxycholic acid and artesunate in the treatment of severe falciparum malaria patients with jaundiceJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 2 2010Sombat Treeprasertsuk Abstract Background and Aims:,Plasmodium falciparum (PF) infection can lead to severe complications. Ursodeoxycholic acid (UDCA) is increasingly used for the treatment of cholestatic liver diseases. The present study aims to determine the effects of combined UDCA and artesunate compared to placebo and artesunate on the improvement of liver tests in severe PF jaundiced patients. Methods:, All severe PF jaundiced patients, aged , 15 years and diagnosed as having severe malaria according to WHO 2000 criteria, were enrolled. Patients with evidence of biliary obstruction, other cholestatic liver diseases and those who were pregnant were excluded. Patients were randomized to receive either oral UDCA or placebo for 2 weeks in additional to artesunate. All patients were admitted for at least 14 days to monitor the result of the treatment. Results:, Seventy-four severe PF malaria patients with jaundice were enrolled. Both groups had similar demographic and laboratory tests, with the exception being more males in the UDCA group than in the placebo group (P = 0.04). The median of percentage change of total bilirubin and aminotransferase levels at the end of weeks 1, 2, 3 and 4 showed no difference between the two groups. Only the median of percentage change of alkaline phosphatase at the end of week one compared with the baseline values showed less increment in the UDCA group than in the placebo group (P = 0.04). No serious adverse events were seen during the 4 weeks of follow up. Conclusions:, In severe PF malaria patients with jaundice, combined therapy with UDCA and artesunate is safe, but does not significantly improve liver tests compared to placebo and artesunate. [source] Post-cholecystectomy biliary strictures: Not always benignJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 7pt2 2008Ajay Sharma Abstract Background:, Post-cholecystectomy malignant biliary obstruction masquerading as benign biliary stricture (BBS) has not been reported in the literature; it presents a diagnostic and management challenge. Methods:, Of the 349 post-cholecystectomy BBS managed at a tertiary care hospital in northern India between 1989 and 2004, 11 patients were found to have biliary malignancy. Records of these 11 patients were analyzed retrospectively for the purpose of this study. Results:, Mean age of patients with malignant biliary strictures was significantly higher (52 vs 38 years, P = 0.000); they were more likely to have jaundice (100% vs 78%, P = 0.008) and pruritus (82% vs 48%, P = 0.03). Unlike most patients with BBS referred from elsewhere to us, they had had a smooth postoperative course uncomplicated by bile leak, had a longer cholecystectomy-presentation interval, and were more likely to have high strictures ((Bismuth type III/IV) 91% vs 49%, P = 0.008). Conclusions:, Post-cholecystectomy biliary obstruction is not always benign. High bilirubin levels and hilar strictures, especially after an uneventful cholecystectomy, in a middle-aged patient should raise a suspicion of underlying missed malignancy. [source] Evaluation of the biliary tract: The value of performing magnetic resonance cholangiopancreatography in conjunction with a 3-D spoiled gradient-echo gadolinium enhanced dynamic sequenceJOURNAL OF MEDICAL IMAGING AND RADIATION ONCOLOGY, Issue 4 2007SJ Kim Summary The 3-D gradient-echo (GRE) sequence allows thinner sections and better resolution of biliary obstruction. When the presence of biliary obstruction is identified using magnetic resonance cholangiopancreatography, the addition of the 3-D GRE sequence may be helpful for diagnosing biliary obstruction. By showing the changes in the bile duct wall, within the duct lumen and around the bile duct, this technique can be helpful for distinguishing benign from malignant stricture as well as a stone from an enhancing intraluminal mass. [source] Anterior abdominal wall defects and biliary obstructionJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 3 2005L Teoh Abstract:, Three infants with anterior abdominal wall defects (gastroschisis and exomphalos) who presented with obstructive jaundice secondary to biliary obstruction, are described. All three infants had abnormal biliary systems, with mechanical distortion of the biliary tree. Biliary obstruction secondary to structural biliary anomalies should be considered in patients with abdominal wall defects and cholestasis, as prolonged unrelieved biliary obstruction may lead to biliary cirrhosis and portal hypertension. [source] Pomegranate peel extract prevents liver fibrosis in biliary-obstructed ratsJOURNAL OF PHARMACY AND PHARMACOLOGY: AN INTERNATI ONAL JOURNAL OF PHARMACEUTICAL SCIENCE, Issue 9 2007Hale Z. Toklu ABSTRACT Punica granatum L. (pomegranate) is a widely used plant that has high nutritional value. The aim of this study was to assess the effect of chronic administration of pomegranate peel extract (PPE) on liver fibrosis induced by bile duct ligation (BDL) in rats. PPE (50 mg kg,1) or saline was administered orally for 28 days. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) levels were determined to assess liver function and tissue damage. Proinflammatory cytokines (tumor necrosis factor-alpha and interleukin 1 beta) in the serum and anti-oxidant capacity (AOC) were measured in plasma samples. Samples of liver tissue were taken for measurement of hepatic malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO) activity and collagen content. Production of reactive oxidants was monitored by chemilumi-nescence assay. Serum AST, ALT, LDH and cytokines were elevated in the BDL group compared with the control group; this increase was significantly decreased by PPE treatment. Plasma AOC and hepatic GSH levels were significantly depressed by BDL but were increased back to control levels in the PPE-treated BDL group. Increases in tissue MDA levels and MPO activity due to BDL were reduced back to control levels by PPE treatment. Similarly, increased hepatic collagen content in the BDL rats was reduced to the level of the control group with PPE treatment. Thus, chronic PPE administration alleviated the BDL-induced oxidative injury of the liver and improved the hepatic structure and function. It therefore seems likely that PPE, with its antioxidant and antifibrotic properties, may be of potential therapeutic value in protecting the liver from fibrosis and oxidative injury due to biliary obstruction. [source] Yin-Chen-Hao-Tang ameliorates obstruction-induced hepatic apoptosis in ratsJOURNAL OF PHARMACY AND PHARMACOLOGY: AN INTERNATI ONAL JOURNAL OF PHARMACEUTICAL SCIENCE, Issue 4 2007Tzung-Yan Lee The accumulation of hydrophobic bile acids in the liver is considered to play a pivotal role in the induction of apoptosis of hepatocytes during cholestasis. Thus, factors that affect apoptosis may be used to modulate liver fibrosis. Yin-Chen-Hao-Tang (YCHT) decoctions have been recognised as a hepatoprotective agent for jaundice and various types of liver diseases. We used an experimental rat model of bile-duct ligation (BDL) to test whether YCHT plays a regulatory role in the pathogenesis of hepatic apoptosis. BDL-plus-YCHT groups received 250 or 500 mg kg,1 YCHT by gavage once daily for 27 days. YCHT significantly ameliorated the portal hypertensive state and serum TNF-, compared with the vehicle-treated control group. In BDL-plus-YCHT-treated rats, hepatic glutathione contents were significantly higher than than in BDL-only rats. BDL caused a prominent liver apoptosis that was supported by an increase in Bax and cytochrome c protein and increased expression of Bax and Bcl-2 messenger RNA. The normalising effect of YCHT on expression of Bax and Bcl-2 mRNA was dependent on the dose of YCHT, 500 mg kg,1 having the greater effect on both Bax and Bcl-2 of mRNA levels. Additionally, YCHT treatment down-regulated both hepatic caspase-3 and ,8 activities of BDL rats. This study demonstrates the anti-apoptotic properties of YCHT and suggests a potential application of YCHT in the clinical management of hepatic disease resulting from biliary obstruction. [source] Protective effect of melatonin against oxidative stress induced by ligature of extra-hepatic biliary duct in rats: comparison with the effect of S-adenosyl- l -methionineJOURNAL OF PINEAL RESEARCH, Issue 3 2000Pedro Montilla López In the present research, we studied the effect of the administration of melatonin or S-adenosyl- l -methionine (S-AMe) on oxidative stress and hepatic cholestasis produced by double ligature of the extra-hepatic biliary duct (LBD) in adult male Wistar rats. Hepatic oxidative stress was evaluated by the changes in the amount of lipid peroxides and by the reduced glutathione content (GSH) in lysates of erythrocytes and homogenates of hepatic tissue. The severity of the cholestasis and hepatic injury were determined by the changes in the plasma enzyme activities of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (AP), g-glutamyl-transpeptidase (GGT), and levels of albumin, total bilirubin (TB) and direct bilirubin (DB). Either melatonin or S-AMe were administered daily 3 days before LBD, and for 10 days after biliary obstruction. LDB caused highly significant increases in plasma enzyme activities and in bilirubin and lipid peroxides levels in erythrocytes and hepatic tissue. At the same time, this procedure produced a notable decrease in the GSH pools in these biological media. Both melatonin and S-AMe administration were effective as antioxidants and hepatoprotective substances, although the protective effects of melatonin were superior; it prevented the GSH decrease and reduced significantly the increases in enzyme activities and lipid peroxidation products produced by biliary ligature. S-AMe did not modify the increased GGT activity nor did it decrease greatly the TB levels (43% melatonin vs. 14% S-AMe). However, S-AMe was effective in preventing the loss of GSH in erythrocytes and hepatic tissue, as was melatonin. The obtained data permit the following conclusions. First, the LDB models cause marked hepatic oxidative stress. Second, the participation of free radicals of oxygen in the pathogenecity and severity of cholestasis produced by the acute obstruction of the extra-hepatic biliary duct is likely. Third, the results confirm the function of S-AMe as an antioxidant and hepatoprotector. Finally, melatonin is far more potent and provides superior protection as compared to S-AMe. Considering the decrease in oxidative stress and the intensity of cholestasis, these findings have interesting clinical implications for melatonin as a possible therapeutic agent in biliary cholestasis and parenchymatous liver injury. [source] Pathogenesis and outcome of extrahepatic biliary obstruction in catsJOURNAL OF SMALL ANIMAL PRACTICE, Issue 6 2002P. D. Mayhew Extrahepatic biliary obstruction (EHBO) was confirmed at surgery or necropsy in 22 cats. Biliary or pancreatic adenocarcinoma was diagnosed by histopathology in six cats and one cat had an undiagnosed mass in the common bile duct. The remaining 15 cats had at least one of a complex of inflammatory diseases including pancreatitis, cholangiohepatitis, cholelithiasis and cholecystitis. The most common clinical signs were jaundice, anorexia, lethargy, weight loss and vomiting. Hyperbilirubinaemia was present in all cases. Distension of the common bile duct and gall bladder was the most commonly observed finding on abdominal ultrasound. Nineteen cats underwent exploratory laparotomy for biliary decompression and diversion. Mortality in cats with underlying neoplasia was 100 per cent and, in those with non-neoplastic lesions, was 40 per cent. Long-term complications, in those that survived, included recurrence of cholangiohepatitis, chronic weight loss and recurrence of obstruction. Based on these findings, the prognosis for EHBO in cats must be considered guarded. [source] Retrospective Study: Surgical intervention in the management of severe acute pancreatitis in cats: 8 cases (2003,2007)JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue 4 2010Tolina T. Son DVM Abstract Objective , To evaluate clinical characteristics and outcomes of cats undergoing surgical intervention in the course of treatment for severe acute pancreatitis. Design , Retrospective observational study from 2003 to 2007 with a median follow-up period of 2.2 years (range 11 d,5.4 y) postoperatively. Setting , Private referral veterinary center. Animals , Eight cats. Interventions , None. Measurements and Main Results , Quantitative data included preoperative physical and clinicopathologic values. Qualitative parameters included preoperative ultrasonographic interpretation, perioperative and intraoperative feeding tube placement, presence of free abdominal fluid, intraoperative closed suction abdominal drain placement, postoperative complications, microbiological culture, and histopathology. Common presenting clinical signs included lethargy, anorexia, and vomiting. Leukocytosis and hyponatremia were present in 5 of 8 cats. Hypokalemia, increased total bilirubin, and hyperglycemia were present in 6 of 8 cats. Elevated alanine aminotransferase and aspartate transferase were present in all cats. Surgery for extrahepatic biliary obstruction was performed in 6 cats, pancreatic abscess in 3 cats, and pancreatic necrosis in 1 cat. Six of the 8 cats survived. Five of the 6 cats that underwent surgery for extrahepatic biliary obstruction and 1 cat that underwent pancreatic necrosectomy survived. All 5 of the cats with extrahepatic biliary obstruction secondary to pancreatitis survived. The 2 nonsurvivors included a cat with a pancreatic abscess and a cat with severe pancreatitis and extrahepatic biliary obstruction secondary to a mass at the gastroduodenal junction. Postoperative complications included progression of diabetes mellitus, septic peritonitis, local gastrostomy tube stoma inflammation, local gastrostomy tube stoma infection, and mild dermal suture reaction. Conclusion , Cats with severe acute pancreatitis and concomitant extrahepatic biliary obstruction, pancreatic necrosis, or pancreatic abscesses may benefit from surgical intervention. Cats with extrahepatic biliary obstruction secondary to severe acute pancreatitis may have a good prognosis. [source] Liver test patterns in patients with acute calculous cholecystitis and/or choledocholithiasisALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 9 2009M. S. PADDA Summary Background, Liver tests are utilized to determine the presence of biliary obstruction. Aim, To examine our hypothesis that liver tests aid in elucidating whether patients have simple calculous cholecystitis (ACC) or choledocholithiasis (CDL). Methods, We performed a retrospective study of patients admitted to two University of Texas Southwestern teaching hospitals with a clinical picture consistent with ,acute gallstone disease', i.e. cholecystitis ± choledocolithiasis. The presence of ACC and CDL was based on defined clinical criteria. Results, The cohort consisted of 154 patients meeting specific entry criteria, primarily with right upper quadrant pain; 62 ACC, 79 both ACC and CDL and 13 CDL alone. Approximately 30% of patients with ACC had abnormal alkaline phosphatase (ALP) and/or bilirubin level and approximately 50% had abnormal aminotransferase levels. Among patients with ACC/CDL, 77% had abnormal ALP, 60% had abnormal bilirubin and 90% had abnormal aminotransferase levels. By multivariate analysis, increasing common bile duct size and an abnormal ALP and alanine aminotransferase (ALT) were excellent predictors of having ACC with CDL. Conclusions, Liver test patterns can aid in elucidating CDL, including in ACC patients. Fundamentally, patients with CDL were more likely to have more abnormal liver tests, whether they had CDL only, or CDL and ACC. A dilated CBD, and abnormal ALP and ALT had modest sensitivity and high specificity for identification of patients with ACC and CDL. [source] Sclerosing peritonitis and mortality after liver transplantationLIVER TRANSPLANTATION, Issue 4 2009Kristin Mekeel Sclerosing peritonitis describes the development of a peel or rind of fibrosis that spreads over the peritoneal surface and can lead to recalcitrant ascites, bowel obstruction, and sepsis. It is well described as a complication of peritoneal dialysis, especially with episodes of bacterial peritonitis. It is also a complication of end-stage liver disease with ascites and liver transplantation. This article describes 3 cases of sclerosing peritonitis present at the time of liver transplantation or soon after. All 3 patients had massive refractory ascites with episodes of spontaneous bacterial peritonitis prior to transplantation. Two patients had evidence of a fibrous peel at the time of transplantation. Postoperatively, all 3 patients continued to have refractory ascites and episodes of peritonitis, along with partial small bowel obstructions, abdominal pain, and malnutrition. Two patients also had constriction of the graft, including biliary obstruction and inferior vena cava and outflow obstruction, which has not been previously described. All 3 patients eventually died from complications related to the sclerosing peritonitis. Liver Transpl 15:435,439, 2009. © 2008 AASLD. [source] Antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice: is it worth the cost?ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 4 2002B. F. Thompson Background: There are few published data concerning the economic impact of antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography in the setting of biliary obstruction. Aim: To perform decision analysis to determine the costs of prophylaxis in patients undergoing endoscopic retrograde cholangiopancreatography for obstructive jaundice. Methods: A decision analysis model was constructed. The probability of biliary sepsis, death and endoscopic retrograde cholangiopancreatography complications was obtained from the medical literature and from a retrospective analysis of our own experience. Costs were obtained from Medicare reimbursement at our institution. The strategies evaluated were endoscopic retrograde cholangiopancreatography with and without single-dose antibiotic prophylaxis. We compared the total costs, number of episodes of cholangitis and deaths associated with each strategy. Results: Based on published data and the results of our retrospective analysis, the strategy of administering single-dose prophylactic antibiotics prior to endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice resulted in lower total costs, fewer episodes of cholangitis and fewer deaths compared to a strategy of not administering antibiotics. The results were sensitive to the rates of cholangitis, cost of antibiotics and the cost of treating an episode of cholangitis. Conclusions: Antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography results in fewer cases of cholangitis and is cost saving when compared to a strategy of no prophylaxis in patients with obstructive jaundice. [source] Association of mast cells and liver allograft rejectionPEDIATRIC TRANSPLANTATION, Issue 3 2008Cigdem Arikan Abstract:, MCs are important effector cells in a broad range of immune responses. Their role in liver allograft rejection is not clear. Twenty-one liver transplant recipients (mean age ± s.d.; 10.2 ± 4.1 yr) who experienced a rejection episode are included in this study. Biopsy specimens from normal livers (allograft biopsy with normal histopathology n = 5 and naďve livers n = 6), transplanted livers with CR (n = 5), and transplanted livers with ACR (n = 26) were studied. The total number of PT in each biopsy specimen was documented, and the number of PT that contained MCs was expressed as a percentage of the total number of PT. MCs, percentage of PT containing MCs and the average number of MCs/PT was significantly higher in rejection specimens than in control biopsy samples. All parameters were significantly higher in CR group than AR groups. Increasing grades of rejection was also associated with progressively more MCs and MC/PT (r = 0.68 p = 0.000; r = 0.58 p = 0.002). Only serum bilirubin level was related to the MCs in AR group. Only MC/PT was detected as an independent predictor of graft survival (p = 0.011, RR 2.87 95% CI 1.3,6.5). Despite the fact that the role of MCs in liver allograft rejection is still unknown; they exist in inflammatory infiltrates during pediatric liver allograft rejection. MC-rich portal infiltrates may distinguish chronic liver rejection from other inflammatory states such as AR, hepatitis and biliary obstruction. [source] Safety of endoscopic retrograde cholangiopancreatography during pregnancyANZ JOURNAL OF SURGERY, Issue 1-2 2009Mohammed N. Bani Hani Abstract Background:, The risk of choledocholithiasis is expected to be higher during pregnancy. This is attributed to alteration in bile composition as well as biliary stasis that take place during gestation. There is significant concern regarding application of endoscopic procedures especially the more invasive ones for treatment of choledocholithiasis during pregnancy. Our aim was to provide an additional support to the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the management of biliary diseases during pregnancy. Methods:, The medical records of 10 pregnant patients who underwent ERCP at King Abdullah University Hospital, during the period from 2002 to 2007 were reviewed. Pregnancy course and outcomes were followed up in all cases. Results were analysed and compared with published data on safety and efficacy of this procedure. Results:, The mean age for mothers was 24.3 years. The mean duration of gestation was 18.4 weeks. Two patients were in the first trimester, five were in their second trimester and another three in the third trimester. The main indication for ERCP was obstructive choledocholithiasis on ultrasound and liver function tests. Fetal radiation exposure was not routinely measured. During, or after, the procedure there was no need for tocolytic agents. Also there was no intrauterine fetal distress. Screening for congenital anomalies was negative in all cases. Conclusion:, Major complications of biliary obstruction have been prevented through this procedure. Short-term follow up for all neonates whom mothers underwent ERCP during pregnancy supports its safety. However, specific long-term fetal complications of radiation exposure have not been investigated yet. [source] Rate of bilirubin regression after stenting in malignant biliary obstruction for the initiation of chemotherapyCANCER, Issue 11 2008How soon should we repeat endoscopic retrograde cholangiopancreatography? Abstract BACKGROUND. This study was conducted to evaluate the rate of regression of bilirubin after stent placement for malignant biliary obstruction. METHODS. Records were reviewed from October 2002 to September 2005 for patients who underwent endoscopic retrograde cholangiopancreatography with stent placement. The time to achieve a bilirubin level ,2 mg/dL was the primary endpoint because this is the level required by most chemotherapy protocols. Patient variables included type of cancer, liver metastasis, recent chemotherapy, baseline creatinine, and international normalized ratio (INR). Stent variables included type, dimension, stricture location, and sphincterotomy. RESULTS. In total, 156 patients were included in the analysis: Ninety-three patients achieved a poststent bilirubin level ,2 mg/dL, 29 patients failed because of stent failure, and 34 patients failed because of inadequate follow-up. The time required for 80% of patients to achieve normalization was more than doubled in those who had prestent bilirubin levels ,10 mg/dL (6 weeks) compared with those who had prestent bilirubin levels <10 mg/dL (3 weeks). The following variables were identified as statistically significant: prestent bilirubin level, stricture location, liver metastasis, and INR. The cancer type, recent chemotherapy, stent type and diameter, and sphincterotomy were not statistically significant variables. CONCLUSIONS. The rate of bilirubin normalization after biliary stenting was highly dependent on the prestent bilirubin level. Endoscopic intervention should be considered in patients who fail to achieve adequate normalization of serum bilirubin in 6 weeks if prestent bilirubin level was ,10 mg/dL and in 3 weeks if their prestent bilirubin level was <10 mg/dL. Independent variables, such as diffuse liver metastases, stricture outside the common bile duct, and elevated INR had predictive value for bilirubin normalization. Cancer 2008. © 2008 American Cancer Society. [source] Recurrent hepatitis C virus disease after liver transplantation and concurrent biliary tract complications: poor outcomeCLINICAL TRANSPLANTATION, Issue 4 2006Lior H. Katz Abstract:, Recurrent hepatitis C virus (HCV) infection is particularly aggressive in the post-liver transplantation setting, with rapid progression of liver fibrosis. Biliary complications remain a significant cause of morbidity following liver transplantation. Post-cholecystectomy biliary strictures are associated with advanced hepatic fibrosis. The aim of this retrospective study was to determine whether the presence of biliary complications affects survival in liver transplant recipients with recurrent HCV disease. The files of liver transplant recipients (53.7% male; mean age 52.7 ± 10.3 yr) were reviewed for incidence, type and treatment of biliary complications, and findings were compared between those who developed recurrent HCV disease (n = 47, 83.9%) and those who did not (n = 9). Twenty-one biliary complications developed in 12 patients with recurrent HCV (25.5%). Treatment with endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography with balloon dilatation and stent placement or surgical revision was successful in nine (75%). Three biliary complications developed in three patients with no recurrence (p = NS). There was no statistically significant association between recurrent HCV disease and biliary complications. However, among those with recurrent disease, the recurrence was severe in nine of 12 recipients with biliary complications (75%) but in only nine of 35 without biliary complications (26%) (p = 0.001). Death was documented in eight patients with severe recurrence (44.4%), including three (37.5%) with biliary complications and two (7%) with non-severe recurrence, neither of whom had biliary complications (p = 0.003). Antiviral treatment was successful in nine of 25 patients (36%) who received it. On multivariate analysis, biliary complications were a significant predictor of severe recurrence (OR 27.0, 95% confidence interval 2.07,351.4) (p = 0.012). Fibrosis stage in the second biopsy was significantly correlated with serum alanine aminotransferase (p = 0.01) and with duration of biliary obstruction (p = 0.07). In conclusion, biliary complications of liver transplantation strongly affect outcome in patients with recurrent HCV disease despite attempts to relieve the biliary obstruction and to treat the recurrent HCV disease. [source] Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstructionJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 11 2008Rungsun Rerknimitr Abstract Background:, Self-expandable metallic stents (SEMS) are known to provide a longer patency time than plastic stents for malignant biliary obstructions including hilar obstruction. However, studies that focus on the efficacy of SEMS in low-grade and advanced hilar obstructions are still scanty. Methods:, Ninety four patients with malignant hilar obstructions were enrolled (six were later excluded). Patients were divided into two groups according to their Bismuth levels. Group A were patients with Bismuth I (n = 53). Group B were patients with Bismuth II, III and IV (n = 35). Technical success, complications, jaundice resolution, stent patency time, and patients' survival were analyzed. Results:, Our intention-to-treat analysis showed that group A had a significant lower rate of post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis than group B; 16.1% versus 44.7%, (P < 0.01). Four patients from group B still had persistent jaundice. Our per protocol analysis demonstrated that median stent patency time in groups A and B were not statistically different (74 vs 60 days). Median survival time in groups A and B were also not statistically different (90 vs 75 days). In both groups, those without liver metastasis had significantly better patency and survival time than those with liver metastasis (P = 0.010 and 0.027, respectively). Conclusions:, In patients with hilar obstruction, liver metastasis is one of the main factors that determine survival of the patient. Patency times of SEMS in both low-grade and advanced obstructions are comparable. However, in the advanced group, there is a significant risk of post-ERCP cholangitis. [source] | |||||||||||||||||||||||||