Portal cholangiopathy: case report

The present report describes the case of a child that after blunt abdominal trauma presented with portal thrombosis followed by progressive splenomegaly and jaundice. Ultrasonography and percutaneous cholangiography revealed biliary dilatation secondary to choledochal stenosis caused by dilated peribiliary veins, characterizing a case of portal biliopathy. The present case report is aimed at presenting an uncommon cause of this condition.

Adenomioma da papila de vater em adulto jovem

The authors report a case of adenomyoma of papilla of Vater in a young adult, a rare pathology in this age and site. The commonest clinical findings are abdominal pain, dyspepsia and jaundice, as in this case in which the patient referred these symptoms for several months. The diagnosis is usually difficult before surgery, because the radiological and endoscopic appearances are difficult to interpret, since they may only show obstruction and enlargement of the biliary tract; in this way, the endoscopic biopsy may be useful. In the present case the computed tomography, abdominal scan and intraoperative cholangiography only demonstrated obstruction and enlargement of the biliary tract, without the presence of gallstones. The treatment is usually lesion resection according to its size, performing the total resection in those cases of extensive involvement of the digestive tract, as it was performed in this case, due to the dimension of the lesion and its malignant appearance. The patient was discharged from hospital on the thirteenth postoperative day, with a histological diagnosis of adenomyoma of papilla of Vater. Three months after the procedure the patient was asymptomatic.

Vesícula residual

Our objective is to report three patients with recurrent severe upper abdominal pain secondary to residual gallbladder. All patients had been subjected to cholecystectomy from 1 to 20 years before. The diagnosis was established after several episodes of severe upper abdominal pain by imaging exams: ultrasonography, tomography, or endoscopic retrograde cholangiography. Removal of the residual gallbladder led to complete resolution of symptoms. Partial removal of the gallbladder is a very rare cause of postcholecystectomy symptoms.

Colecistectomia laparoscópica em um paciente com ducto cístico duplo

Our objective is to report a case of laparoscopic cholecystectomy in a patient with duplicated cystic duct. A 34 year old male presented with episodic pain in the upper rigth quadrant of the abdomen. Murphy' s sign was not present. Ultrassonography showed gallbladder with multiple calculi and a thickened wall. At laparoscopic cholecystectomy, a duplicated cystic duct was found. Careful dissection and intraoperative cholangiography were performed to rule out common bile duct injury.

Comparison between open and laparoscopic elective cholecystectomy in elderly, in a teaching hospital

Objective: to analyze the differences in mortality rates, length of hospital stay, time of surgery and the conversion rate between elective open cholecystectomies (OC) and laparoscopic ones (LC) in elderly patients. Methods : we evaluated medical records of patients 65 years of age or older undergoing open or laparoscopic cholecystectomy at the Hospital Regional de Mato Grosso do Sul between January 2008 and December 2011. We excluded individuals operated in non-elective scenarios or who underwent intraoperative cholangiography. Results : we studied 113 patients, of whom 38.1% were submitted to the OC and 61.9%, to LC. Women accounted for 69% of patients and men, for 31%. The conversion rate was 2.9%. The mean age and duration of the procudure was 70.1 and 84 minutes, respectively, with no significant difference between OC and LC. Patients undergoing LC had shorter hospital stays (2.01 versus 2.95 days, p=0.0001). We identified operative complications in sixpatients (14%) after OC and in nine (12%) after LC, with no statistical difference. Conclusion : there was no difference in morbidity and mortality when comparing OC with LC. The laparoscopic approach led to shorter hospital stay. Operative time did not differ between the two access routes. The conversion rate was similar to other studies.

Histopathological diagnosis of intra- and extrahepatic neonatal cholestasis

The histopathology of the liver is fundamental for the differential diagnosis between intra- and extrahepatic causes of neonatal cholestasis. However, histopathological findings may overlap and there is disagreement among authors concerning those which could discriminate between intra- and extrahepatic cholestasis. Forty-six liver biopsies (35 wedge biopsies and 11 percutaneous biopsies) and one specimen from a postmortem examination, all from patients hospitalized for neonatal cholestasis in the Pediatrics Service of Hospital de Clínicas de Porto Alegre, were prospectively studied using a specially designed histopathological protocol. At least 4 of 5 different stains were used, and 46 hepatic histopathological variables related to the differential diagnosis of neonatal cholestasis were studied. The findings were scored for severity on a scale from 0 to 4. Sections which showed less than 3 portal spaces were excluded from the study. Sections were examined by a pathologist who was unaware of the final diagnosis of each case. Bile tract permeability was defined by scintigraphy of the bile ducts and operative cholangiography. The F test and discriminant analysis were used as statistical methods for the study of the hepatic histopathological variables. The chi-square method with Yates correction was used to relate the age of the patients on the date of the histopathological study to the discriminatory variables between intra- and extrahepatic cholestasis selected by the discriminant function test. The most valuable hepatic histopathological variables for the discrimination between intra- and extrahepatic cholestasis, in decreasing order of importance, were periportal ductal proliferation, portal ductal proliferation, portal expansion, cholestasis in neoductules, foci of myeloid metaplasia, and portal-portal bridges. The only variable which pointed to the diagnosis of intrahepatic cholestasis was myeloid metaplasia. Due to the small number of patients who were younger than 60 days on the date of the histopathological study (N = 6), no variable discriminated between intra- and extrahepatic cholestasis before the age of 2 months and all of them, except for the portal expansion, were discriminatory after this age. In infants with cholestasis, foci of myeloid metaplasia, whenever present in the liver biopsy, suggested intrahepatic cholestasis. Periportal ductal proliferation, portal ductal proliferation, portal expansion, cholestasis in neoductules, portal cholestasis and portal-portal bridges suggested extrahepatic obstructive cholestasis.

Delay in gallbladder emptying during the perimenopausal period

A pilot study has ascribed an important role in gallbladder motility and emptying to the perimenopausal period. To assess the effect of this period on gallbladder emptying and cholelithogenesis, 25 women in the perimenopausal period without gallbladder disease were submitted to cholangiography and two ultrasound exams. The time for gallbladder emptying and the presence of cholelithiasis were assessed. All patients presented a delay in gallbladder emptying with no relationship to the pre- or postmenopausal period. This finding was not related to lithogenesis. Gallbladder emptying time is longer during the perimenopausal period.

Valor diagnostico de la colangioresonancia para la detección de coledocolitiasis en pancreatitis aguda Hospital Mederi-Bogotá

La pancreatitis aguda (PA) es una patología clínica común que abarca un espectro desde leve hasta fatal, donde se produce una inflamación del páncreas por auto digestión enzimática con grado variable de compromiso sistémico. Es una emergencia abdominal grave con una mortalidad del 9-23%. En el 40% de los casos de pancreatitis aguda se encuentra que es de origen biliar. La prevalencia de enfermedad biliar a nivel mundial en adultos varía entre 5,9% y 21,9%, con grandes variaciones geográficas y regionales, se encuentran en el 12% de los hombres y el 24% de las mujeres. La prevalencia aumenta con la edad. Latinoamérica es una región con alta prevalencia. En pacientes con colelitiasis del 5-15 % tienen coledocolitiasis. La alta prevalencia de la patología biliar en nuestro país hace que esta sea una causa frecuente de consulta médica por dolor abdominal. El factor común presente en la gran mayoría de las enfermedades de la vía biliar es la Colelitiasis. La complicación más frecuente, la Coledocolitiasis, se ha reportado con cifras hasta de un 20% y como complicación de esta la pancreatitis. La pancreatitis aguda de origen biliar (PAB) es causada por una obstrucción transitoria o persistente de la ampolla de Váter por barro biliar o por cálculos. En el diagnostico de la PAB se emplean métodos invasivos como la colangiopancreaticografia endoscópica retrograda (CPRE) la cual trae consigo morbilidad y mortalidad asociada y métodos no invasivos como la colangiopancreaticografia magnética (CRM) que emerge como modalidad prometedora en el diagnostico y manejo de la PAB en centros de tercer y cuarto nivel de complejidad. El manejo actual de la PAB es la remoción de la obstrucción del conducto biliar común (CBC) seguida de su tratamiento definitivo, la colecistectomía o CPRE con papilotomia. En nuestro país no se han publicado estudios con datos locales acerca de la utilidad de la CRM para la detección de coledocolitiasis, en las guías de manejo de coledocolitiasis de la asociación colombiana de cirugía publicadas en el año 2004, hace referencia de la utilidad de la CRM para el diagnostico de esta entidad tomando como base una revisión sistemática de estudios publicados en Medline, Pubmed y Cocrane los cuales no incluyen experiencia a nivel nacional. En este estudio pretendimos determinar cuáles son los pacientes que se benefician de la realización de CRM temprana en el marco de la PAB leve para la detección de coledocolitiasis.

Comparación de CPRE temprana y tardia en pacientes con pancreatitis aguda severa de origen biliar

INTRODUCCION: La obstrucción biliar es la principal causa de pancreatitis aguda y su curso es moderado a leve aunque un 20% desarrollan formas severas. La remoción de los cálculos por CPRE se ha empleado como terapéutica aunque su rol es controversial y no se ha demostrado su utilidad en forma temprana. El propósito de este estudio es observar la evolución de los pacientes con PASB en quienes se realice CPRE con respecto al curso de la enfermedad. METODOLOGIA: Estudio retrospectivo observacional descriptivo en pacientes con PASB llevados a CPRE. Entre junio y octubre de 2012 se encontraron 72 pacientes con PASB y patrón biliar obstructivo, 49 (68.06%) en los cuales se realizo de forma temprana (antes de 72 horas) y 23 (31,94 %) de forma tardía (después de las 72 horas). RESULTADOS: No se encontraron diferencias en la morbilidad entre los dos grupos observados. Se encontró una mayor incidencia de PASB en mujeres, no hubo complicaciones asociadas al procedimiento y no hubo mortalidad asociada en ninguno de los grupos. DISCUSION: El estudio no muestra que la realización de CPRE tardía influya de forma desfavorable en los pacientes con PASB. Se encontró mayor incidencia de PASB en mujeres y edad media de 61 años. Deben realizarse mas estudios como el presente con un mayor número de pacientes para demostrar que no hay aumento en la morbimortalidad en los pacientes que sean llevados a CPRE después de 72 horas de inicio de los síntomas y poder generar recomendaciones de manejo locales.

Aspectos microbiológicos da bile de pacientes com suspeita de coledocolilitíase e suas repercussões no tratamento das infecções biliares

A infecção das vias biliares é uma doença freqüente com alta morbidade e mortalidade, que pode variar de 10 a 60% dependendo de sua gravidade. A causa mais comum desta infecção é a presença de cálculos na via biliar principal que propicia o surgimento de bacteriobilia. O profundo conhecimento das características microbiológicas da bile nos casos de coledocolitíase e infecção das vias biliares são fundamentais para o melhor diagnóstico desta infecção e escolha da antibioticoterapia a ser instituída. Assim, o objetivo deste estudo foi de caracterizar os principais aspectos microbiológicos da bile dos pacientes com e sem coledocolitíase e avaliar sua importância na escolha dos antimicrobianos para o tratamento da infecção das vias biliares. Foram analisados 33 pacientes que foram divididos em um grupo de 10 pacientes sem coledocolitíase (grupo controle) no momento da Colangiografia Endoscópica (CPER) e em outro grupo de 23 pacientes com coledocolitíase. A bile de todos os pacientes foi coletada no início do procedimento endoscópico, através de catater introduzido na via biliar. O exame de microscopia direta com coloração de Gram e as culturas da bile foram negativas nos 10 pacientes que não apresentaram coledocolitíase durante a CPER. Dos 23 pacientes com cálculos na via biliar principal, 19 (83%) apresentaram culturas positivas. Desses 19 pacientes com culturas de bile positivas, 18 (94,7%) apresentaram microorganismos detectáveis à microscopia direta com coloração de Gram. Apenas um paciente apresentou crescimento de germe anaeróbio (Bacteroides fragilis). O cultivo de 28 bactérias teve predominância de microorganismos Gram negativos (18 bactérias- 64,3%). Os germes isolados foram E. coli (9, 32,1%), Klebsiella pneumoniae (5, 17,9%), Enterococcus faecalis (5, 17,9%), Streptococcus alfa-haemoliticus (3, 10,7%), Streptococcus viridans (2, 7,1%), Enterobacter cloacae (2, 7,1%), Panteona aglomerans (1, 3,6%) e Pseudomonas aeruginosa (1, 3,6%). Todos os pacientes com microorganismos detectados pela microscopia direta com coloração de Gram tiveram crescimento bacteriano em suas culturas, por outro lado nenhum paciente com cultura negativa apresentou microoorganismos à microsopia direta ( p= 0,0005). Nesses casos, a microsopia direta apresentou uma especificidade de 100% e sensibilidade de 80%. A análise quantitativa das culturas da bile mostrou que das 19 culturas positivas, 12 (63,2%) tiveram pelo menos um germe com contagem superior a 105 ufc/ml. Todas as bactérias Gram positivas isoladas foram sensíveis à ampicilina, da mesma forma que todas as Gram negativas foram sensíveis aos aminoglicosídeos. Os achados deste estudo demonstram uma boa correlação entre a microscopia direta da bile com coloração de Gram e os achados bacteriológicos das culturas da bile coletada por colangiografia endoscópica retrógrada. O esquema terapêutico antimicrobiano tradicionalmente empregado em nosso hospital, que inclui a combinação de ampicilina e gentamicina, parece ser adequado, pois apresenta eficácia terapêutica contra os principais microorganismos responsáveis pela infecção das vias biliares.

Ocorrência de infecção hospitalar em idosos internados em hospital universitário

OBJETIVO: A infecção hospitalar é uma importante causa de morbidade e mortalidade na população idosa. O estudo realizado teve como objetivo avaliar a ocorrência e os fatores de risco da infecção hospitalar. MÉTODOS: Realizou-se estudo prospectivo em uma amostra de 322 idosos com 60 anos e mais, internados em um hospital universitário, entre setembro de 1999 e fevereiro de 2000. O cálculo da amostra foi feito pela fórmula de Fisher e Belle, com intervalo de confiança de 0,95%, de um total de 760 idosos internados, proporcionalmente ao número de pacientes em cada unidade de internação, no ano de 1997. Os critérios para definição da infecção hospitalar foram os do Center for Diseases and Prevention Control. Para a análise estatística dos dados foram utilizados o odds ratio e regressão logística. RESULTADOS: A taxa de infecção hospitalar encontrada foi de 23,6%. As topografias prevalentes de infecção hospitalar foram infecção respiratória (27,6%), do trato urinário (26,4%) e do sítio cirúrgico (23,6%). O tempo de internação dos pacientes sem infecção hospitalar foi de 6,9 dias e dos com infecção hospitalar foi de 15,9 (p<0,05). A taxa de mortalidade dos pacientes internados foi de 9,6% e a de letalidade dos pacientes com infecção hospitalar de 22,9% (p<0,05). Os fatores de risco encontrados para infecção hospitalar foram colangiografia (odds ratio (OR)=46,4, intervalo de confiança 95% (IC 95%)=4,4-485); diabetes melito (OR=9,9, IC 95%=4,4-22,3); doença pulmonar obstrutiva crônica (OR=8,3, IC 95%=2,9-23,7); cateterismo urinário (OR=5, IC 95%=2,7-11,8); internação com infecção comunitária (OR=3,9, IC 95%=1,7-8,9) e ventilação mecânica (OR=3,8, IC 95%=1,9-6,3). CONCLUSÕES: A infecção hospitalar apresentou incidência e letalidade elevadas e aumentou o tempo de internação dos idosos estudados.

Management of gallstone disease in children: a new protocol based on the experience of a single center

Background/purpose: Gallstones and cholelithiasis are being increasingly diagnosed in children owing to the widespread use of ultrasonography. The treatment of choice is cholecystectomy, and routine intraoperative cholangiography is recommended to explore the common bile duct. The objectives of this study were to describe our experience with the management of gallstone disease in childhood over the last 18 years and to propose an algorithm to guide the approach to cholelithiasis in children based on clinical and ultrasonographic findings. Methods: The data for this study were obtained by reviewing the records of all patients with gallstone disease treated between January 1994 and October 2011. The patients were divided into the following 5 groups based on their symptoms: group 1, asymptomatic; group 2, nonbiliary obstructive symptoms; group 3, acute cholecystitis symptoms; group 4, a history of biliary obstructive symptoms that were completely resolved by the time of surgery; and group 5, ongoing biliary obstructive symptoms. Patients were treated according to an algorithm based on their clinical, ultrasonographic, and endoscopic retrograde cholangiopancreatography (ERCP) findings. Results: A total of 223 patients were diagnosed with cholelithiasis, and comorbidities were present in 177 patients (79.3%). The most common comorbidities were hemolytic disorders in 139 patients (62.3%) and previous bariatric surgery in 16 (7.1%). Although symptoms were present in 134 patients (60.0%), cholecystectomy was performed for all patients with cholelithiasis, even if they were asymptomatic; the surgery was laparoscopic in 204 patients and open in 19. Fifty-six patients (25.1%) presented with complications as the first sign of cholelithiasis (eg, pancreatitis, choledocolithiasis, or acute calculous cholecystitis). Intraoperative cholangiography was indicated in 15 children, and it was positive in only 1 (0.4%) for whom ERCP was necessary to extract the stone after a laparoscopic cholecystectomy (LC). Preoperative ERCP was performed in 11 patients to extract the stones, and a hepaticojejunostomy was indicated in 2 patients. There were no injuries to the hepatic artery or common bile duct in our series. Conclusions: Based on our experience, we can propose an algorithm to guide the approach to cholelithiasis in the pediatric population. The final conclusion is that LC results in limited postoperative complications in children with gallstones. When a diagnosis of choledocolithiasis or dilation of the choledocus is made, ERCP is necessary if obstructive symptoms persist either before or after an LC. Intraoperative cholangiography and laparoscopic common bile duct exploration are not mandatory. Published by Elsevier Inc.

Biliary Drainage in Patients With Unresectable, Malignant Obstruction Where ERCP Fails Endoscopic Ultrasonography-Guided Choledochoduodenostomy Versus Percutaneous Drainage

Background: Endoscopic retrograde cholangiopancreatography may fail because of malignant involvement of the second portion of the duodenum and the major papilla. Alternatives include percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CD) has been reported as an alternative. Objective: To prospectively compare EUS-CD and PTBD in patients with unresectable malignant biliary obstruction. Design: Prospective and randomized study. Setting: Tertiary center. Main Outcome Measurements: Success and efficacy comparison EUS-CD with PTBD. Results: Twenty-five subjects were randomized (13 EUS-CD and 12 PTBD). Mean age was 67 years (SD, 11.9). The 2 groups were similar before intervention in terms of quality of life [EUS-CD (58.3) vs. PTBD (57.8); P = 0.78], total bilirubin (16.4 vs. 17.2; P = 0.7), alkaline phosphatase (539 vs. 518; P = 0.7), and gamma-glutamyl transferase (554.3 vs. 743.5; P = 0.56). All procedures were technically and clinically successful in both groups. At 7-day follow-up there was a significant reduction in total bilirubin in both the groups (EUS-CD, 16.4 to 3.3; P = 0.002 and PTBD, 17.2 to 3.8; P = 0.01), although no difference was noted comparing the 2 groups (EUS-CD to PTBD; 3.3 vs. 3.8; P = 0.2). There was no difference between the complication rates in the 2 groups (P = 0.44), EUS-CD (2/13; 15.3%) and PTBD (3/12; 25%). Costs were similar in the 2 groups also ($5673-EUS-CD vs. $7570-PTBD; P = 0.39). Limitations: Small sample size and single center study. Conclusions: EUS-CD can be an effective and safe alternative to PTBD with similar success, complication rate, cost, and quality of life.

Common bile duct stones: analysis of the videolaparoscopic surgical treatment

CONTEXT: About 9% of the Brazilian population has gallstones and the incidence increases significantly with aging. The choledocholithiasis is found around 15% of these patients, and a third to half of these cases presented as asymptomatic. Once the lithiasis in the common bile duct is characterized through intraoperative cholangiography, the laparoscopic surgical exploration can be done through the transcystic way or directly through choledochotomy. OBJECTIVE: To evaluate the results and outcomes of the laparoscopic treatment of common bile duct lithiasis. METHODS: Seventy consecutive patients were evaluated. They prospectively underwent the treatment of the lithiasis in the common bile duct and the exploration ways were compared according to the following parameters: criteria on their indication, success in the clearance, surgical complications. It was verified that about ½ of the choledocholithiasis carriers did not show any expression of predictive factors (clinical antecedents of jaundice and/or acute pancreatitis, compatible sonographic data and the pertaining lab tests). The laparoscopic exploration through the transcystic way is favored when there are no criteria for the practice of primary choledochotomy, which are: lithiasis in the proximal bile duct, large (over 8 mm) or numerous calculi (multiple calculosis). RESULTS: The transcystic way was employed in about 50% of the casuistic and the choledochotomy in about 30%. A high success rate (around 80%) was achieved in the clearance of the common bile duct stones through laparoscopic exploration. The transcystic way, performed without fluoroscopy or choledochoscopy, attained a low rate of success (around 45%), being 10% of those by transpapilar pushing of calculi less than 3 mm. The exploration through choledochotomy, either primary or secondary, if the latter was performed after the transcystic route failure, showed high success rate (around 95%). When the indication to choledochotomy was primary, the necessity for choledochoscopy through choledochotomy to help in the removal of the calculi was 55%. However, when choledochotomy was performed secondarily, in situations where the common bile duct diameter was larger than 6 mm, the use of choledochoscopy with the same purpose involved about 20% of the cases. There was no mortality in this series. CONCLUSION: The laparoscopic exploration of the common bile duct was related to a low rate of morbidity. Therefore, the use of laparoscopy for the treatment of the lithiasis in the common bile duct depends on the criteria for the choice of the best access, making it a safe procedure with very good results.

Applicazioni cliniche e sperimentali dell’ecografia toracica in pneumologia: la diagnostica precoce delle patologie pleuropolmonari

Lung ultrasound use is increasing in respiratory medicine thanks to its development in the latest years. Actually it allows to study diseases of the chest wall (traumas, infections, neoplasms), diaphragm (paralysis, ipokinesis), pleura (effusions, pneumothorax, thickenings, neoplasms) and lung parenchyma (consolidations, interstitial syndromes, peripheral lesions). One of the most useful application of chest ultrasound is the evaluation of effusions. However, no standardized approach for ultrasound-guided thoracenthesis is available. Our study showed that our usual ultrasonographic landmark (“V-point”) could be a standard site to perform thoracenthesis: in 45 thoracenthesis no pneumothorax occurred, drainage was always successful at first attempt. Values of maximum thickness at V-point and drained fluid volume showed a significative correlation. Proteins concentration of ultrasound patterns of effusions (anechoic, ipoechoic, moving echoic spots, dense moving spots, hyperechoic) were compared to those of the macroscopic features of fluids showing connection between light-yellow fluid and echoic moving spots pattern and between ipoechoic/dense moving spots and cloudy-yellow/serum-haematic fluids. These observations suggest that ultrasound could predict chemical-physical features of effusions. Lung ultrasound provides useful information about many disease of the lung, but actually there is not useful in obstructive bronchial diseases. Analysing diaphragmatic kinetics using M-mode through transhepatic scan we described a similarity between diaphragm excursion during an expiratory forced maneuver and the volume/time curve of spirometry. This allowed us to identify the M-mode Index of Obstruction (MIO), an ultrasound-analogue of FEV1/VC. We observed MIO values of normal subjects (9) and obstructed patients (9) comparing the two groups. FEV1/VC and MIO showed a significant correlation suggesting that MIO may be affected by airways obstruction; MIO values were significatively different between normal and obstructed so that it could identify an obstructive syndrome. The data show that it is possible to suspect the presence of obstructive syndrome of the airways using ultrasonography of the diaphragm.