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Radiological studies play a crucial role in the evaluation of patients with biliary duct obstruction, allowing for the guidance of clinical diagnosis towards a malignant or stone-induced etiology through the recognition of relevant imaging features, which must be continuously revisited given their prognostic significance. This article aims to emphasize the importance of recognizing crucial imaging aspects of malignant and stone-induced biliary obstruction.
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INTRODUCTION AND IMPORTANCE: Portal biliopathy (PB) is an abnormality of the biliary tree wall due to extrahepatic portal hypertension. Among the complications of portal biliopathy are digestive bleeding, jaundice, and cholangitis. Surgical treatment is an exception when medical management is not possible. CASE PRESENTATION: This is a case series study of four patients with severe PB complications requiring surgical management in our center from 2005 to 2016. Two of them had previous surgical procedures related to portal hypertension. All presented with severe biliary stenosis and recurrent cholangitis, and two also had massive upper gastrointestinal bleeding. Because of endoscopic management failure, a Roux-en-Y hepaticojejunostomy was performed in all cases. Two patients presented morbidity Clavien-Dindo>IIIA, requiring reoperation. During follow-up, no one developed other complications related to PB. DISCUSSION: Surgical treatment for PB complications is a challenge and mainly implies a portosystemic shunt as a first step. When it fails, an alternative is perform a biliodigestive anastomoses, with high risk of bleeding given the prominent collaterals present in the hepatoduodenal pedicle secondary to portal cavernomatosis. CONCLUSION: Our patients after YRGB didn't present new complications due to PB. The surgery could be a definite solution for PB complications. It has only been made for selective cases because it implies high complexity and risk.
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In Malignant Hilar Biliary Stricture (MHBS) palliative biliary drainage is a frequent strategy, improving the quality of life, reducing pruritus, loss of appetite and relieving cholangitis. The endoscopic approach is an effective, although challenging procedure. This study aimed to evaluate technical and clinical success rates of biliary drainage by ERCP. This is a retrospective study including all patients with MHBS referred to Instituto do Cancer do Hospital de São Paulo (ICESP) submitted to biliary drainage by ERCP, between January 2010 and December 2017. Multivariable logistic regression was performed to evaluate predictors of clinical failure, as total bilirubin levels, Bismuth classification, number of hepatic sectors drained and presence of cholangitis. In total, 82 patients presenting unresectable MHBS were included in this study. 58.5% female and 41.5% male, with a mean age of 60±13 years. Bismuth classification grades II, IIIA, IIIB and IV were noted in 23.2%, 15.9%, 14.6% and 46.3%, respectively. Technical and clinical success was achieved in 92.7% and 53.7% respectively. At multivariable logistic-regression analyses, Bismuth IV strictures were related to higher clinical failure rates when compared to other strictures levels, with an Odds Ratio of 5.8 (95% CI 1.28â20.88). In conclusion, endoscopic biliary drainage for malignant hilar biliary stricture had a high technical success but suboptimal clinical success rate. Proximal strictures (Bismuth IV) were associated with poor drainage outcomes.
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Colangite , Colestase , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Constrição Patológica/cirurgia , Estudos Retrospectivos , Bismuto , Qualidade de Vida , Brasil , Colestase/cirurgia , Drenagem/métodos , Stents , Resultado do TratamentoRESUMO
Abstract In Malignant Hilar Biliary Stricture (MHBS) palliative biliary drainage is a frequent strategy, improving the quality of life, reducing pruritus, loss of appetite and relieving cholangitis. The endoscopic approach is an effective, although challenging procedure. This study aimed to evaluate technical and clinical success rates of biliary drainage by ERCP. This is a retrospective study including all patients with MHBS referred to Instituto do Cancer do Hospital de São Paulo (ICESP) submitted to biliary drainage by ERCP, between January 2010 and December 2017. Multivariable logistic regression was performed to evaluate predictors of clinical failure, as total bilirubin levels, Bismuth classification, number of hepatic sectors drained and presence of cholangitis. In total, 82 patients presenting unresectable MHBS were included in this study. 58.5% female and 41.5% male, with a mean age of 60±13 years. Bismuth classification grades II, IIIA, IIIB and IV were noted in 23.2%, 15.9%, 14.6% and 46.3%, respectively. Technical and clinical success was achieved in 92.7% and 53.7% respectively. At multivariable logistic-regression analyses, Bismuth IV strictures were related to higher clinical failure rates when compared to other strictures levels, with an Odds Ratio of 5.8 (95% CI 1.28‒20.88). In conclusion, endoscopic biliary drainage for malignant hilar biliary stricture had a high technical success but suboptimal clinical success rate. Proximal strictures (Bismuth IV) were associated with poor drainage outcomes.
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PURPOSE: To describe a novel technique of percutaneous transhepatic (PTH) placement of a plastic biliary stent (PBS), report the feasibility and safety of the technique, and present the preliminary results of a pilot study that included 32 patients with symptomatic obstructive jaundice (SOJ) treated with the technique. MATERIALS AND METHODS: This was a prospective, single-arm, single-center, pilot study of a cohort of patients with the diagnosis of benign or malignant obstructive jaundice that underwent PTH placement of a PBS to relieve the obstruction. RESULTS: Thirty-two patients were included, 16 men and 16 women (age range, 35-88 years). There were 26 malignant and six benign lesions. Cholangiocarcinoma was the most common tumor (n=13, 40.6%), followed by pancreatic adenocarcinoma (n=6, 18.75%) and metastasis (n=5, 15.6%). A total of 35 PBSs were placed in 32 procedures. The bile duct was accessed and drained to the right side in 18 cases, to the left side in 14 cases, and bilaterally in three cases. Technical success was achieved in 100% and clinical success in 93.7% of cases. Using a modified Bismuth-Cortelle classification system, type I was observed in nine patients, type II in nine patients, type III in six patients, and type IV in eight patients. The mean follow-up was 426.1 days for the total sample, and 349.4 days for patients with malignancy. Two complications were observed: transient hemobilia and cholangitis. CONCLUSION: PTH placement of a PBS in patients with SOJ is feasible, safe, and effective.
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Adenocarcinoma , Neoplasias dos Ductos Biliares , Colestase , Neoplasias Pancreáticas , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Ductos Biliares Intra-Hepáticos , Drenagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Plásticos , Estudos Prospectivos , Stents , Resultado do TratamentoRESUMO
OBJECTIVES: In cirrhotic children, infection events and sepsis are more frequent and more severe due to immune dysfunction. The objectives of the current study were therefore to develop an experimental model of infection and sepsis in cirrhotic weaning growing rats, by the use of bile duct ligation (BDL) and cecal ligation and puncture (CLP). Additionally, the correlation of the clinico-histopathological data and serial cytokine levels in septic cirrhotic and non-cirrhotic animals was studied. METHODS: Young Wistar rats of age 21 days and of weight between 70-90 g were divided into 12 groups according to the surgical procedure performed: sham (sacrificed after 2 or 4 weeks), BDL (sacrificed after 2 or 4 weeks), CLP (2- or 4-week old animals sacrificed after 12 or 24 hours), BDL+CLP (2- or 4-week old animals sacrificed after 12 hours). Histopathological studies and determination of serum levels of cytokines IL-1 beta, IL-10, and TNF-alpha, for studies of systemic infection, were performed. Murine sepsis scores (MSS) based on the clinical aspects just before euthanasia were also included. RESULTS: A transitory increase in IL-1, IL-10, and TNF-alpha levels was observed, with different patterns according to the groups. Two-hit groups tended to present with higher values of serum cytokines and histopathological scores than their septic non-cirrhotic counterparts. There was a correlation between mortality rate and MSS (p<0.0001). CONCLUSION: The model is feasible and may be utilized in studies on liver cirrhosis and infection in growing animals.
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Animais , Camundongos , Ratos , Sepse , Cirrose Hepática , Reprodutibilidade dos Testes , Ratos Wistar , Modelos TeóricosRESUMO
ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Colangite/diagnóstico , Icterícia Obstrutiva/diagnóstico , Centros de Atenção Terciária , Hospitais Universitários , Admissão do Paciente/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Bilirrubina/análise , Brasil/epidemiologia , Aceitação pelo Paciente de Cuidados de Saúde , Drenagem , Colangite/cirurgia , Colangite/epidemiologia , Doença Aguda , Estudos Transversais , Estudos Retrospectivos , Sensibilidade e Especificidade , Colangiopancreatografia Retrógrada Endoscópica/estatística & dados numéricos , Icterícia Obstrutiva/cirurgia , Icterícia Obstrutiva/epidemiologia , Confiabilidade dos DadosRESUMO
Resumen Antecedentes y objetivos: la pancreatitis y la colecistitis son complicaciones mayores después de la postura de un stent metálico cubierto en el manejo de la obstrucción biliar distal maligna. Se pretende comparar el uso de un stent biliar cubierto convencional con un nuevo prototipo de stent biliar cubierto de morfología en flor con baja fuerza axial (FA) y fuerza radial (FR), y evaluar el impacto de las cifras de colecistitis y pancreatitis poststent. Métodos: se realizó un estudio prospectivo no aleatorizado en el que se comparó un grupo de 18 pacientes con stent biliar tipo flor (SF) con un grupo de pacientes que recibieron un stent biliar convencional (SC) con una relación 1:2, para el manejo de la obstrucción biliar distal maligna. Se evaluaron datos demográficos; el éxito técnico y clínico; así como la aparición de colecistitis y/o pancreatitis, tasas de migración y/u oclusión. Resultados: se evaluaron 18 pacientes en el grupo con SF (7 hombres, 39 %) con una edad mediana de 72 años y 36 pacientes (16 hombres, 44 %) en el grupo de SC con una edad mediana de 71 años. Se presentaron 3 casos de colecistitis y 4 casos de pancreatitis, todos ellos en el grupo de SC. Al explorar la asociación de los aspectos clínicos con respecto al tipo de stent, el análisis multivariado mostró diferencias estadísticamente significativas en 4 aspectos: la hemoglobina, la longitud de estenosis, la etiología y la oclusión del stent. Al evaluar los tiempos de supervivencia entre los pacientes con SC y SF, no se hallaron diferencias significativas en las funciones de supervivencia (log rank, p = 0,399). En el modelo de riesgos proporcionales de Cox, solo un aspecto mostró diferencias significativas frente a los tiempos de supervivencia: la presencia de metástasis. Conclusiones: el uso de un nuevo prototipo de stent SF (con surcos laterales) con menor FA y FR se relaciona con un menor índice de complicaciones como colecistitis y pancreatitis en comparación con el SC, en la paliación de las estenosis biliares malignas distales sin detrimento de su permeabilidad o migración y sin afectar la supervivencia de estos pacientes.
Abstract Background and objectives: Pancreatitis and cholecystitis are major complications following stenting with covered metallic stents to manage malignant distal biliary obstructions. We compare the use of a conventional covered biliary stent with a new prototype of a covered biliary stent with a flower-pedal structure that uses with low axial force and radial force in order to evaluate impacts on cholecystitis and pancreatitis after stenting. Methods: This is a non-randomized prospective comparison of a group of 18 patients stented with a flower-like biliary stent (FS group) with a group of 36 patients who received conventional biliary stents (CS group) ratio for management of malignant distal biliary obstructions. Demographic data and data about technical and clinical success including the appearance of cholecystitis and/or pancreatitis, migration rates and/or occlusion were evaluated. Results: The 18 FS group patients included 7 men (39%) and had a median age of 72 years. The 36 CS group patients included 16 men (44%) and had a median age of 71 years. There were three cases of cholecystitis and four cases of pancreatitis, all of which were in the CS group. Multivariate analysis showed statistically significant differences between the two groups in four clinical areas: hemoglobin, length of stenosis, etiology and occlusion of stents. No significant differences were found in survival time functions (Log Rank, p = 0.399). In Cox's proportional hazards model, the only significant difference with respect to survival times was found on the issue of whether or not metastasis was present. Conclusions: The use of the new prototype flower-like biliary stent with lateral grooves and lower axial force and radial force is related to a lower rate of complications such as cholecystitis and pancreatitis than the use of conventional stents for palliation of distal malignant biliary stenoses. The new stent has no detriments in terms of permeability or migration and did not affect the survival of these patients.
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Humanos , Masculino , Feminino , Pancreatite , Stents , Colecistite , MétodosRESUMO
BACKGROUND/PURPOSE: Biliary atresia and other liver biliary obstructions are relevant conditions in pediatric surgery due to their progression to biliary cirrhosis and indication for liver transplantation. It is known that the period during which biliary obstruction persists determines the development of cirrhosis and its reversibility after a biliary drainage procedure. However, no time or histological markers of biliary cirrhosis reversibility have been established. MATERIALS AND METHODS: One hundred and twenty-nine young Wistar rats underwent surgery for ligation of the common bile duct and were maintained until 8weeks. A part of these animals was submitted to biliary drainage surgery at 2, 3, 4, 5, or 6weeks after the initial procedure. After cyst formation at the site of obstruction, cyst-jejunal anastomosis was performed to restore bile flow. After biliary obstruction and drainage, liver samples were collected for histological and molecular analysis of the genes responsible for collagen deposition and fibrosis. RESULTS: The mortality rates were 39.8% and 56.7% after the first and second procedures, respectively. Ductular proliferation (p=0.001) and collagen deposition increased according to the period under obstruction (p=0.0001), and both alterations were partially reduced after biliary drainage. There were no significant differences in the values of desmin and α-actin according to the period during which the animal remained with biliary obstruction (p=0.09 and p=0.3, respectively), although increased values of transforming growth factor beta 1 (TGFß1) occurred after 8weeks (p=0.000). Desmin levels decreased, and α-actin and TGFß1 levels increased according to the period under obstruction. The molecular alterations were partially reversed after biliary drainage. CONCLUSIONS: The histologic and molecular changes in the liver parenchyma promoted by biliary obstruction in the young animal can be partially reversed by a biliary drainage procedure.
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Anastomose Cirúrgica , Coledocostomia/métodos , Cirrose Hepática Biliar/cirurgia , Alanina Transaminase/sangue , Animais , Modelos Animais de Doenças , Ratos , Ratos WistarRESUMO
Enfermidades que acometem o sistema biliar dos cães, principalmente as relacionadas a processos obstrutivos, não são raras, sendo em sua maioria, de etiologia grave, necessitando de tratamento cirúrgico. Os métodos de diagnóstico por imagem para investigação de obstruções biliares atualmente realizados na medicina veterinária como a ultrassonografia, radiografia convencional e tomografia computadorizada, apresentam algumas restrições, como sensibilidade insuficiente, e em muitas regiões inviabilidade de realização. Desta forma, vários pacientes são submetidos a procedimentos cirúrgicos antes da obtenção do diagnóstico preciso, que caracterize e identifique o local de obstrução. Neste contexto, o presente trabalho objetivou padronizar e descrever a técnica de colangiografia transcolecística percutânea em cães, consistindo na injeção percutânea de contraste no interior da vesícula biliar por meio de punção ecoguiada, permitindo a visualização e avaliação semiológica das vias biliares intra e extra-hepáticas, mediante projeções radiográficas. A técnica foi executada 10 vezes em seis cães clinicamente saudáveis, sendo a punção da vesícula biliar realizada através do nono espaço intercostal direito próximo ao esterno com auxílio de um cateter 20G, injetando a dose de 1ml de contraste para cada 4kg de peso vivo. Após a injeção do contraste foram efetuadas radiografias seriadas da região abdominal, em projeção lateral esquerda e ventrodorsal, as primeiras projeções foram realizadas imediatamente após a injeção do contraste sendo repetidas após cinco e dez minutos. Nenhum dos animais apresentou quaisquer efeitos colaterais decorrentes da técnica, sendo verificados por meio de observação dos mesmos e provas de função hepática comparativas pré e pós procedimento. A técnica demonstrou eficácia na demonstração radiográfica da árvore biliar, possibilitando a avaliação semiológica das vias biliares intra e extra-hepáticas. Tal avaliação permite identificar, caracterizar e localizar possíveis processos obstrutivos que acometem as vias biliares na espécie canina.(AU)
Obstructive biliary pathway diseases are not rare in dogs, especially those with severe clinical signs and those that need surgical treatment. Image diagnostic exams to evaluate biliary tract, like ultrasound, conventional X-ray and CT, have been used in veterinary medicine with some restrictions such as low sensibility, and in many regions unfeasibility of achievement. Due to this, most of the pacients with biliary obstruction sings are submitted to surgical procedure before an accurate diagnostic of the disease. This paper aimed to standardize and describe the percutaneous transcolecystic cholangiography in dogs that consists in the injection of contrast inside of the gall bladder guided by ultrasound. It allows to see all the bililary tract, using X-ray. The technique was performed 10 times in six clinical healthy dogs. The puncture was performed in the 9th intercostal right space near to the sternum using a 20G catheter, the dose was 1ml per 4kg. After contrast injection, serial radiographs of the abdominal region were made, in left lateral projection and ventrodorsal, the first projections were performed immediately after contrast injection and repeated after five and ten minutes. No animal showed any side effect due to the technique, this was confirmed by observation and by hepatic function evaluation. The technique was considered efficacious to visualize all the biliary tree and to see any possible obstruction in ill dogs.(AU)
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Animais , Cães , Colangiografia/estatística & dados numéricos , Colangiografia/veterinária , Colestase/diagnóstico por imagem , Cães/anormalidadesRESUMO
Enfermidades que acometem o sistema biliar dos cães, principalmente as relacionadas a processos obstrutivos, não são raras, sendo em sua maioria, de etiologia grave, necessitando de tratamento cirúrgico. Os métodos de diagnóstico por imagem para investigação de obstruções biliares atualmente realizados na medicina veterinária como a ultrassonografia, radiografia convencional e tomografia computadorizada, apresentam algumas restrições, como sensibilidade insuficiente, e em muitas regiões inviabilidade de realização. Desta forma, vários pacientes são submetidos a procedimentos cirúrgicos antes da obtenção do diagnóstico preciso, que caracterize e identifique o local de obstrução. Neste contexto, o presente trabalho objetivou padronizar e descrever a técnica de colangiografia transcolecística percutânea em cães, consistindo na injeção percutânea de contraste no interior da vesícula biliar por meio de punção ecoguiada, permitindo a visualização e avaliação semiológica das vias biliares intra e extra-hepáticas, mediante projeções radiográficas. A técnica foi executada 10 vezes em seis cães clinicamente saudáveis, sendo a punção da vesícula biliar realizada através do nono espaço intercostal direito próximo ao esterno com auxílio de um cateter 20G, injetando a dose de 1ml de contraste para cada 4kg de peso vivo. Após a injeção do contraste foram efetuadas radiografias seriadas da região abdominal, em projeção lateral esquerda e ventrodorsal, as primeiras projeções foram realizadas imediatamente após a injeção do contraste sendo repetidas após cinco e dez minutos. Nenhum dos animais apresentou quaisquer efeitos colaterais decorrentes da técnica, sendo verificados por meio de observação dos mesmos e provas de função hepática comparativas pré e pós procedimento... (AU)
Obstructive biliary pathway diseases are not rare in dogs, especially those with severe clinical signs and those that need surgical treatment. Image diagnostic exams to evaluate biliary tract, like ultrasound, conventional X-ray and CT, have been used in veterinary medicine with some restrictions such as low sensibility, and in many regions unfeasibility of achievement. Due to this, most of the pacients with biliary obstruction sings are submitted to surgical procedure before an accurate diagnostic of the disease. This paper aimed to standardize and describe the percutaneous transcolecystic cholangiography in dogs that consists in the injection of contrast inside of the gall bladder guided by ultrasound. It allows to see all the bililary tract, using X-ray. The technique was performed 10 times in six clinical healthy dogs. The puncture was performed in the 9th intercostal right space near to the sternum using a 20G catheter, the dose was 1ml per 4kg. After contrast injection, serial radiographs of the abdominal region were made, in left lateral projection and ventrodorsal, the first projections were performed immediately after contrast injection and repeated after five and ten minutes. No animal showed any side effect due to the technique, this was confirmed by observation and by hepatic function evaluation. The technique was considered efficacious to visualize all the biliary tree and to see any possible obstruction in ill dogs.(AU)
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Animais , Cães , Colangiografia , Colangiografia/veterinária , Colestase/diagnóstico por imagemRESUMO
Pancreatic ductal adenocarcinoma (PDAC) is one of the cancers with poorest prognosis and represents the third leading cause of cancer-related deaths in Western countries. Despite advances in diagnostic procedures and treatment, diagnosis is made in most cases when the disease is locally advanced or metastatic. Supportive care aims to improve symptoms, reduce hospital admission rates, and preserve quality of life. Proper symptomatic management is critical to allow administration of chemotherapy and radiotherapy. Symptomatic management should be accomplished in a multidisciplinary fashion. Its primary aims include relief of biliary or duodenal obstruction, prevention and/or treatment of thromboembolic disease, and control cancer-related pain. Nutritional support and optimal replacement therapy in patients with endocrine and/or exocrine insufficiency, is mandatory. This manuscript highlights the most significant problems faced when caring for patients with advanced PDAC and provides an evidence-based approach to symptomatic management.
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Adenocarcinoma/terapia , Carcinoma Ductal Pancreático/terapia , Cuidados Paliativos , Neoplasias Pancreáticas/terapia , Qualidade de Vida , HumanosRESUMO
ABSTRACT Background. In clinical practice, it is assumed that a severe rise in transaminases is caused by ischemic, viral or toxic hepatitis. Nevertheless, cases of biliary obstruction have increasingly been associated with significant hypertransaminemia. With this study, we sought to determine the true etiology of marked rise in transaminases levels, in the context of an emergency department. Material and methods. We retrospectively identified all patients admitted to the emergency unit at Centro Hospitalar e Universitário de Coimbra between 1st January 2010 and 31st December 2010, displaying an increase of at least one of the transaminases by more than 15 times. All patient records were analyzed in order to determine the cause of hypertransaminemia. Results. We analyzed 273 patients - 146 males, mean age 65.1 ± 19.4 years. The most frequently etiology found for marked hypertransaminemia was pancreaticobiliary acute disease (n = 142;39.4%), mostly lithiasic (n = 113;79.6%), followed by malignancy (n = 74;20.6%), ischemic hepatitis (n = 61;17.0%), acute primary hepatocellular disease (n = 50;13.9%) and muscle damage (n = 23;6.4%). We were not able to determine a diagnosis for 10 cases. There were 27 cases of recurrence in the lithiasic pancreaticobiliary pathology group. Recurrence was more frequent in the group of patients who had not been submitted to early cholecystectomy after the first episode of biliary obstruction (p = 0.014). The etiology of hypertransaminemia varied according to age, cholestasis and glutamic-pyruvic transaminase values. Conclusion. Pancreaticobiliary lithiasis is the main cause of marked hypertransaminemia. Hence, it must be considered when dealing with such situations. Not performing cholecystectomy early on, after the first episode of biliary obstruction, may lead to recurrence.
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Humanos , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Aspartato Aminotransferases/sangue , Biomarcadores/sangue , Cálculos Biliares/sangue , Alanina Transaminase/sangue , Admissão do Paciente , Portugal , Recidiva , Colecistectomia , Cálculos Biliares/cirurgia , Cálculos Biliares/diagnóstico , Cálculos Biliares/etiologia , Regulação para Cima , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Serviço Hospitalar de EmergênciaRESUMO
BACKGROUND: In clinical practice, it is assumed that a severe rise in transaminases is caused by ischemic, viral or toxic hepatitis. Nevertheless, cases of biliary obstruction have increasingly been associated with significant hypertransaminemia. With this study, we sought to determine the true etiology of marked rise in transaminases levels, in the context of an emergency department. MATERIAL AND METHODS: We retrospectively identified all patients admitted to the emergency unit at Centro Hospitalar e Universitário de Coimbra between 1st January 2010 and 31st December 2010, displaying an increase of at least one of the transaminases by more than 15 times. All patient records were analyzed in order to determine the cause of hypertransaminemia. RESULTS: We analyzed 273 patients - 146 males, mean age 65.1 ± 19.4 years. The most frequently etiology found for marked hypertransaminemia was pancreaticobiliary acute disease (n = 142;39.4%), mostly lithiasic (n = 113;79.6%), followed by malignancy (n = 74;20.6%), ischemic hepatitis (n = 61;17.0%), acute primary hepatocellular disease (n = 50;13.9%) and muscle damage (n = 23;6.4%). We were not able to determine a diagnosis for 10 cases. There were 27 cases of recurrence in the lithiasic pancreaticobiliary pathology group. Recurrence was more frequent in the group of patients who had not been submitted to early cholecystectomy after the first episode of biliary obstruction (p = 0.014). The etiology of hypertransaminemia varied according to age, cholestasis and glutamic-pyruvic transaminase values. CONCLUSION: Pancreaticobiliary lithiasis is the main cause of marked hypertransaminemia. Hence, it must be considered when dealing with such situations. Not performing cholecystectomy early on, after the first episode of biliary obstruction, may lead to recurrence.
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Alanina Transaminase/sangue , Aspartato Aminotransferases/sangue , Cálculos Biliares/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Colecistectomia , Serviço Hospitalar de Emergência , Feminino , Cálculos Biliares/diagnóstico , Cálculos Biliares/etiologia , Cálculos Biliares/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Portugal , Valor Preditivo dos Testes , Recidiva , Estudos Retrospectivos , Fatores de Risco , Regulação para CimaRESUMO
Resumen El diagnóstico de las colangiopatías obstructivas por endosonografía biliopancreática (EUS, por sus siglas en inglés) se ha estudiado en profundidad, y existe un extenso reconocimiento de su papel para el diagnóstico de coledocolitiasis, tumores de la encrucijada biliopancreática y síndromes de compresión extrínseca de la vía biliar. La colangitis, la complicación más frecuente de la obstrucción biliar y responsable de gran parte de su morbimortalidad, no se ha relacionado en forma suficiente con los hallazgos endosonográficos. Nuestro estudio buscó definir la validez diagnóstica de la endosonografía en los pacientes con colangitis aguda con el fin de limitar la morbimortalidad del retraso diagnóstico. Se realizó un estudio descriptivo, analizando las historias clínicas de pacientes sometidos a endosonografía biliopancreática, por ictericia obstructiva de cualquier etiología, y quienes posteriormente fueron llevados a colangiopancreatografía retrógrada endoscópica (CPRE) para manejo de obstrucción biliar. Comparamos los hallazgos endosonográficos compatibles con colangitis aguda (engrosamiento de la vía biliar de 1,5 mm o más, presencia de halo pericolangítico de al menos 1,5 cm de longitud y presencia de contenido de ecogenicidad mixta en el interior de la vía biliar) con el drenaje purulento durante la CPRE. Se encontró una alta frecuencia de estos hallazgos en los pacientes con colangitis, y el engrosamiento de las paredes de la vía biliar fue el más común, en el 92,6% de los casos, seguido por la presencia de halo pericolangítico en el 59,3% de los casos y contenido ductal en el 66,7% de los casos. Igualmente, se encontró asociación ascendente de las frecuencias con grado de severidad de la colangitis. Resulta recomendable realizar estudios con un mayor poder estadístico que permitan validar nuestros resultados para una futura inclusión de la EUS en el algoritmo diagnóstico de las guías de práctica clínica en colangitis aguda.
Abstract Diagnosis of obstructive cholangiopathy with biliopancreatic endosonography (BUS) has been extensively studied, and its role in the diagnosis of choledocholithiasis, biliopancreatic junction tumors and extrinsic biliary compression syndromes is widely recognized. Endosonographic diagnosis of cholangitis, a more frequent complication of biliary obstruction which is responsible for much of its morbidity and mortality, has not been sufficiently studied. Our study's objective is to define the diagnostic validity of endosonography for patients with acute cholangitis in order to limit morbidity and mortality due to diagnostic delay. This is a descriptive study that analyzes clinical histories of patients who underwent biliopancreatic endosonography because of obstructive jaundice of any etiology and who later underwent endoscopic retrograde cholangiopancreatography (ERCP) to manage biliary obstruction. We compared endosonographic findings compatible with acute cholangitis: thickening of the bile duct of 1.5 mm or more, periportal halo sign of at least 1.5 cm in length, mixed echogenicity of bile duct content, and purulent drainage during ERCP. Patients with cholangitis most frequently presented thickened gallbladders (92.6% of cases) periportal halo signs (59.3% of cases) and mixed echogenicity of bile duct content (66.7% of cases). We also found an ascending association of frequencies with the degree of severity of cholangitis. Studies with greater statistical power are needed for validation of our results and for future inclusion of EUS in the diagnostic algorithm for clinical practice guidelines in cases of acute cholangitis.
Assuntos
Colangite , Endossonografia , Colestase , Radioterapia Guiada por ImagemRESUMO
Introducción: la colangiopancreatografía retrógrada endoscópica es el procedimiento de elección para el tratamiento de los problemas obstructivos biliares que no requieren cirugía. Cuando ello no es posible, el rendez vous guiado por ultrasonido endoscópico (USE) es una opción para tratar pacientes que de otra manera requerirían un drenaje biliar percutáneo o una cirugía paliativa. Objetivo: demostrar la factibilidad del procedimiento en un caso de obstrucción biliar que no pudo ser resuelto por vía endoscópica convencional. Paciente: se trata de una mujer de 62 años operada en 1967 de un carcinoma renal, con metástasis pulmonar, dos episodios de melena y una ictericia obstructiva de un mes de evolución ocasionada por una lesión de ocupación de espacio que abarcaba proceso uncinado y cabeza de páncreas y obstruía el colédoco, con extensión a duodeno, lo que dificultó el procedimiento endoscópico de drenaje. Las biopsias del tumor tomadas durante la endoscopia reportaron un carcinoma metastático cónsono con un tumor primario renal (T4, M2, T2). Métodos: se practicó USE, punción con aguja fina de vías biliares, inyección de contraste para confirmar la posición de la aguja dentro de las vías biliares, y paso a través de la aguja de una guía metálica flexible para franquear la obstrucción y colocarla en duodeno, con lo cual se pudo realizar la colocación de una prótesis biliar metálica autoexpandible mediante el procedimiento endoscópico convencional. Resultados: la paciente se quejó de dolor toracoabdominal el día del procedimiento y el siguiente, para luego mejorar progresivamente, con tratamiento a base de analgésicos y ciprofloxacina 500 mg VO bid por 7 días, con desaparición de la ictericia y normalización de sus cifras de bilirrubina, lo que permitió luego su tratamiento oncológico con quimioterapia y radioterapia. Conclusión: se presenta un caso de obstrucción biliar no susceptible de cirugía curativa ni de tratamiento endoscópico paliativo convencional, resuelto con el uso de ultrasonido endoscópico mediante un procedimiento de rendez vous.
Introduction: the endoscopic retrograde cholangiopancreatography is the procedure of choice for the treatment of obstructive biliary problems not amenable for curative surgery. When it is not possible, the endoscopic ultrasound (EUS) guided rendez-vous is an option to treat patients that otherwise would require a percutaneous biliary drainage or a palliative surgery. Objective: to demonstrate the factibility of the procedure in a case of biliary obstruction that could not be solved in a conventional endoscopic way. Patient: a 62 years old woman with a renal carcinoma operated in 1967, a pulmonary metastasis, two episodes of melena and an obstructive jaundice caused by a metastatic infiltrative lesion of the head and uncinate process of the pancreas obstructing the common bile duct with invasion to the second portion of the duodenum compromising the usual endoscopic procedure of drainage. Methods: an EUS was performed, with fine needle punction of the bile ducts, injection of contrast to confirm the position of the needle inside the bile ducts, introduction through the needle of a wire guide which was negotiated through the bile duct obstruction and placed into the second portion of the duodenum, to proceed then, after withdrawal of the needle and the echoendoscope, with the placement of a self expanded biliary stent in a conventional endoscopic way. Results: after the procedure the patient complained of thoraco-abdominal pain which persisted the following day to improve progressively, with disappearance of the jaundice and normalization of the bilirrubin allowing her oncologic treatment with chemotherapy and radiotherapy. Conclusión: a case of biliary obstruction not susceptible of curative surgery of conventional palliative treatment is presented, solved with the application of EUS through a rendez vous procedure.
RESUMO
A obstrução biliar extra-hepática é rara em gatos. Entre as várias causas verificam-se as compressivas deorigem traumática; dentre elas encontra-se a hérnia diafragmática. A ultrassonografia é um importantemeio de diagnóstico da obstrução biliar, uma vez que possibilita a visibilização da dilatação do sistemabiliar, principalmente em casos crônicos. Este artigo relata o caso de uma gata sem raça definida de oitomeses de idade que apresentou obstrução biliar extra-hepática em consequência de uma hérnia diafragmáticacrônica, onde houve deslocamento do duodeno para o tórax levando consigo o ducto colédoco,causando compressão deste e dilatação do sistema biliar. A hérnia diafragmática foi diagnosticada pelaradiografia simples. A ultrassonografia permitiu o diagnóstico da obstrução biliar bem como determinara cronicidade do caso devido a dilatação dos ductos biliares intra-hepáticos. O animal foi encaminhadopara laparotomia para correção da hérnia, porém foi à óbito no final do procedimento. Foi realizadanecropsia para avaliação macroscópica do parênquima hepático e do sistema biliar e as característicasvistas estavam de acordo com as observadas no momento da ultrassonografia, mostrando o quão útil éeste exame para o diagnóstico da obstrução biliar e para determinar o grau de dilatação biliar.(AU)
The extrahepatic biliary obstruction is rare in cats. The compressive traumatic obstruction, specifically thediaphragmatic hernia, is amongst the various causes. The sonography is an important to biliary obstructiondiagnosis, since it allows the visualization of the biliary system dilatation, in particular the chronic cases.This study reports a extrahepatic biliary obstruction, result of a chronic diaphragmatic hernia, in a femalemongrel cat, eight months old. At the radiography exam of the torax was observed the displacement of theduodenum and the common bile duct to the chest. The sonography confirmed the diagnosis of biliary obstruction and enabled to determine the chronicity of the case due to dilatation of the intrahepatic bile ducts.The surgery for hernia reduction was realized, but the animal died after the surgical procedure. Necropsywas performed for macroscopic evaluation of the hepatic parenchyma and biliary system. The finds wereseen according to the sonographic examination, demonstrating how useful is the sonography for biliaryobstruction diagnosis and to determine biliary dilatation degree.(AU)
Assuntos
Animais , Feminino , Gatos , Ultrassonografia/veterinária , Colestase/veterinária , Hérnia Diafragmática/veterinária , Constrição Patológica/veterinária , BileRESUMO
A obstrução biliar extra-hepática é rara em gatos. Entre as várias causas verificam-se as compressivas deorigem traumática; dentre elas encontra-se a hérnia diafragmática. A ultrassonografia é um importantemeio de diagnóstico da obstrução biliar, uma vez que possibilita a visibilização da dilatação do sistemabiliar, principalmente em casos crônicos. Este artigo relata o caso de uma gata sem raça definida de oitomeses de idade que apresentou obstrução biliar extra-hepática em consequência de uma hérnia diafragmáticacrônica, onde houve deslocamento do duodeno para o tórax levando consigo o ducto colédoco,causando compressão deste e dilatação do sistema biliar. A hérnia diafragmática foi diagnosticada pelaradiografia simples. A ultrassonografia permitiu o diagnóstico da obstrução biliar bem como determinara cronicidade do caso devido a dilatação dos ductos biliares intra-hepáticos. O animal foi encaminhadopara laparotomia para correção da hérnia, porém foi à óbito no final do procedimento. Foi realizadanecropsia para avaliação macroscópica do parênquima hepático e do sistema biliar e as característicasvistas estavam de acordo com as observadas no momento da ultrassonografia, mostrando o quão útil éeste exame para o diagnóstico da obstrução biliar e para determinar o grau de dilatação biliar.
The extrahepatic biliary obstruction is rare in cats. The compressive traumatic obstruction, specifically thediaphragmatic hernia, is amongst the various causes. The sonography is an important to biliary obstructiondiagnosis, since it allows the visualization of the biliary system dilatation, in particular the chronic cases.This study reports a extrahepatic biliary obstruction, result of a chronic diaphragmatic hernia, in a femalemongrel cat, eight months old. At the radiography exam of the torax was observed the displacement of theduodenum and the common bile duct to the chest. The sonography confirmed the diagnosis of biliary obstruction and enabled to determine the chronicity of the case due to dilatation of the intrahepatic bile ducts.The surgery for hernia reduction was realized, but the animal died after the surgical procedure. Necropsywas performed for macroscopic evaluation of the hepatic parenchyma and biliary system. The finds wereseen according to the sonographic examination, demonstrating how useful is the sonography for biliaryobstruction diagnosis and to determine biliary dilatation degree.
Assuntos
Feminino , Animais , Gatos , Colestase/veterinária , Hérnia Diafragmática/veterinária , Ultrassonografia/veterinária , Bile , Constrição Patológica/veterináriaRESUMO
Portal hypertensive biliopathy (PHB) is characterized by anatomical and functional abnormalities of the intrahepatic, extrahepatic and pancreatic ducts, in patients with portal hypertension associated to extrahepatic portal vein obstruction and less frequently to cirrhosis. These morphological changes, consisting in dilatation and stenosis of the biliary tree, are due to extensive venous collaterals occurring in an attempt to decompress the portal venous blockage. It is usually asymptomatic until it progresses to more advanced stages with cholestasis, jaundice, biliary sludge, gallstones, cholangitis and finally biliary cirrhosis. Imaging modalities of the biliary tree such as Doppler ultrasound, computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography are essential to establish the diagnosis and the need of therapeutical interventions. Once the diagnosis is established, treatment with ursodesoxycholic acid seems to be beneficial. Decompression of the biliary tree to dilate, remove stones or implant biliary prosthesis by endoscopic or surgical procedures (hepato-yeyunostomy) usually resolves the cholestatic picture and prevents septic complications. The ideal treatment is the decompression of the portal system, with transjugular intrahepatic porto-systemic shunt or a surgical porto-systemic shunt. Unfortunately, few patients will be candidates for these procedures due to the extension of the thrombotic process. The purpose of this paper is to report the first 3 cases of PHB seen in a Colombian center and to review the literature.
RESUMO
PURPOSE: The aim of this study was to investigate alterations compatible with hepatic ischemia-reperfusion after bilioduodenal shunt (BD) in rats with obstructive jaundice (OB) . METHODS: Thirty six animals were divided into 6 experimental groups: CO1 and CO2 - control groups, sham-operated (SO) and evaluated 6 and 24 hours after, respectively; OB1 and OB2, - obstructive jaundice groups, sham-operated 15 days after bile duct ligature and evaluated 6 and 24 hours after SO, respectively; DBD1and DBD2 - obstructive jaundice groups evaluated ,respectively, 6 and 24 hours after BD performed 15 days after bile duct ligature. The parameters evaluated were serum total bilirubin, aminotransferase activity (AST, ALT), TNFalpha, liver mitochondrial functions and parenchymatous injury. RESULTS: Bilirubin decreased while aminotransferase activity increased 6 hours after BD (p<0.01); TNFalpha determination at the 6th hour after BD was higher than the one at the 24th hour (p<0.05); oxygen consumption in states 3 and 4 remained elevated in the BD initial phase , and liver cell damage worsened 24 hours after BD. CONCLUSION: The results demonstrated that surgical biliary decompression in obstructive jaundice is followed by alterations related to hepatic ischemia- reperfusion.(AU)
OBJETIVO: O objetivo do estudo foi investigar alterações compatíveis com o fenômeno de isquemia-reperfusão hepática em ratos com icterícia obstrutiva (OB) após derivação bilioduodenal (BD). MÉTODOS: Trinta e seis animais foram divididos em seis grupos experimentais: CO1 e CO2 - grupos controle avaliados com 6 e 24 horas após operação simulada (SO), respectivamente; OB1 e OB2 - grupos com obstrução biliar, submetidos a SO 15 dias após ligadura do ducto biliar, e avaliados em 6 e 24 horas após a SO, respectivamente; DBD1 e DBD2 - grupos com 15 dias de obstrução biliar, avaliados em 6 e 24 horas, respectivamente, após BD. Os parâmetros avaliados foram bilirrubinas, aminotranferases (ALT e AST), funções mitocondriais hepáticas, dosagem de TNFalfa e lesão do parênquima hepático. RESULTADOS: As bilirrubinas caíram após BD, enquanto as aminotransferases aumentaram 6 horas após BD (p<0,01). O TNFalfa mensurado na 6ª hora após a BD foi maior que o da 24ª hora (p<0,05). O consumo de oxigênio no estado 3 e 4 mantiveram-se elevados na fase inicial do BD e as lesões celulares hepáticas agravaram-se na 24ª hora pós BD. CONCLUSÃO: Os resultados demonstraram que a descompressão cirúrgica biliar na icterícia obstrutiva foi seguida de alterações que correspondem ao fenômeno de isquemia-reperfusão hepática.(AU)