BACKGROUND : Anomalous pancreaticobiliary ductal union (APBDU) is a congenital defect defined as a union of the pancreatic and the biliary ducts located outside the duodenal wall. Accordingly, this anomalous connection between the choledochus and the pancreatic duct is considered to be a factor in the development of biliary tract diseases such as choledochal cysts, pancreatitis, cholangitis, gallbladder cancer, and bile duct cancer. Our purpose is to analyze combined disease, especially biliary neoplasm, and to evaluate biliary tract microscopic changes in the biliary tract. METHODS : To study the clinical characteristics of APBDU, we reviewed 21 APBDU cases which were treated from June 1994 to January 1998. We studied the associated diseases, the surgical treatment, histological findings and the PCNA expression. We also analyzed the gallbladder epithelium in 10 control patients without APBDU. RESULTS : Among the 21 cases, 12 cases were accompanied by a choledochal cyst. A gallbladder carci noma occurred in 5 cases. Of the 13 operations, 4 involved a cholecystectomy only, and 9 involved a cholecystectomy, bile duct resection and hepaticojejunostomy. The histologic findings were reviewed in 13 cases. Bile duct metaplasia was found in 8 of the 9 cases with a bile duct resection, and gallbladder metaplasia was found in 8 of the 12 cases whereas metaplasia was detected in 1 of the 10 control patients. The PCNA expression was significantly high in APBDU group. CONCLUSIONS : The patients with APBDU showed a high incidence of gallbladder carcinoma and meta plasia in the epithelium of the gallbladder and the bile duct. This metaplasia in the gallbladder and the bile duct was thought to be related to the cancerous change.
Bile Duct Neoplasms ; Bile Ducts* ; Bile* ; Biliary Tract ; Biliary Tract Diseases ; Cholangitis ; Cholecystectomy ; Choledochal Cyst ; Common Bile Duct ; Congenital Abnormalities ; Epithelium ; Gallbladder Neoplasms ; Gallbladder* ; Humans ; Incidence ; Metaplasia ; Noma ; Pancreatic Ducts ; Pancreatitis ; Proliferating Cell Nuclear Antigen

BACKGROUND/AIMS: The biliary tract often shows various morphologic abnormalities. Thus various anomalies and variations of the cystic duct have been extensively studied via cadeveric or intraoperative dissections and operative cholangiograms. The knowledge of the junction of cystic and common hepatic duct is essential for endoscopic management of biliary tract disease. But no large series identifying this critical cystico-hepatic junction(CHJ) by duodenoscopy has been reported. METHODS: To know the anomaly and variant of CHJ and to evaluate its clinical significence, we retrospectively reviewed 434 cases of endoscopic retrograde cholangiography performed at Korea University Hospital from 1992 through 1993. The CHJ was categorized as lateral or medial only for unequivocal angulation in that direction, and spiral when there is overlap of the CHJ with the bile duct in the posteroanterior view. The CHJ was further modified as parallel if the course of the two ducts was closely adherent for 1 cm or more. In addition to identifying the radial takeoff, the level of the CHJ along the length of the extrahepatic biliary tree was determined. The distance from the ampulla to the junction was divided by the distance from the ampulla to the bifurcation and expressed as proximal, middle, distal, respectively. RESULTS: The level of CHJ was mainly middle in 68.4% followed by distal in 16.4%, prximal in 15.2%. The radial orientation of CHJ was mainly lateral in 51.6%, followed by spiral in 32.3%, medial in 16.1%. The cystic duct runs parallely in 11.5%, mainly in the distally inserted, medially oriented cystic duct. The incidence of abnormalous CHJ was 5 case(1.2%), which included 1 case of cystic duct entering the right hepatic duct, 3 case of cystic duct entering at the junction of both extrahepatic duct(trifurcation), and 1 case of accessory hepatic duct entering cystic duct. The most common biliary disease by ERCP was gallbladder stone(25.5%), followed by common bile duct stone(19.5%), intrahepatic duct stone(7.2%), cystic duct obstruction(4.5%), cystic duct stone(2.9%), and others(bile duct cancer, gallbladder cancer, Mirizzi's syndrome). According to the level of the CHJ, there were low incidence of gallbladder stone in distal CHJ, low incidence of common bile duct stone in proximal CHJ and high incidence of Mirrizi's syndrome and gallbladder cancer in distal CHJ. There were no difference in the incidence of biliary disease according to the radial orientation and course of the CHJ. Practically, during therapeutic ERCP there were some tdchnical difficulties in extraction of biliary stone or selective bile duct cannulation in the presence of distally inserted, parallel course of the cystic duct. CONCLUSIONS: The anatomy of the CHJ by ERCP is more variable than that of previous surgical and autopsy reports and the endoscopist should be aware of this variants for safe and effective intervention in bile duct disease.
Autopsy ; Bile Duct Diseases ; Bile Ducts ; Biliary Tract ; Biliary Tract Diseases ; Catheterization ; Cholangiography* ; Cholangiopancreatography, Endoscopic Retrograde ; Common Bile Duct ; Cystic Duct ; Duodenoscopy ; Gallbladder ; Gallbladder Neoplasms ; Hepatic Duct, Common ; Incidence ; Korea ; Retrospective Studies

The Mirizzi syndrome is a rare benign cause of obstructive jaundice. It is particularly interesting to surgeons because the surgery has to be carefully planned to avoid unnecessary damage to the common bile duct. Furthermore, it gives a differential diagnosis dilemma for surgeons as well as radiologist because there are no diagnostic procedures or clinical features that have a perfect access. As a result, the Mirizzi syndrome often has been mistaken for gallbladder cancer and cholangiocarcinoma. We experienced of a 76-year-old male patient, whose clinical symptoms were jaundice, epigastric pain and fever with chill and misdiagnosed as a cholangiocarcinoma with liver metastasis.
Aged ; Bile Duct Diseases ; Cholangiocarcinoma* ; Cholelithiasis ; Cholestasis ; Common Bile Duct ; Cystic Duct ; Diagnosis, Differential ; Fever ; Gallbladder Neoplasms ; Humans ; Jaundice ; Jaundice, Obstructive ; Liver ; Male ; Mirizzi Syndrome* ; Neoplasm Metastasis

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult to perform in patients with a Billroth II anastomosis due to the anatomical alterations. This study evaluated retrospectively the efficacy and safety of endoscopic balloon dilatation after a partial infundibulotomy with a needle knife in patients who had undergone a Billroth II operation. METHODS: Between January 1, 2004 and December 31, 2005, 11 patients, who had undergone a prior Billroth II gastrectomy, underwent ERCP because of a suspicion of pancreatobiliary diseases. Infundibulotomy was performed using a needle knife sphincterotome. After a partial infundibulotomy, a dilation balloon was passed over a prepositioned guidewire and placed in the biliary orifice. Under endoscopic and fluoroscopic control, the balloon was then inflated with diluted contrast over a period of 1 to 2 minutes. RESULTS: A total of 10 patients (7 male and 3 female) were enrolled in this study. Eight had common bile duct stones, 1 bile duct cancer, and 1 pancreatic cancer. The common bile duct was dilated by a balloon. The calculi were removed in 6 patients, and a common bile duct stent was implanted in two cases via endoscopy. No complications such as acute pancreatitis or apparent infections of the biliary tracts were encountered in these cases except for mild fever, temporary high serum levels of aminotransferase and amylase after ERCP in 3 cases. No severe bleeding or perforation occurred in patients undergoing balloon dilatation. CONCLUSIONS: An infundibulotomy with balloon dilatation is a valuable alternative to endoscopic sphinterotomy in the treatment of patients with bile duct diseases, who have undergone prior Billroth II gastrectomies.
Amylases ; Bile Duct Diseases ; Bile Duct Neoplasms ; Biliary Tract ; Calculi ; Cholangiopancreatography, Endoscopic Retrograde ; Common Bile Duct ; Dilatation* ; Endoscopy ; Fever ; Gastrectomy ; Gastroenterostomy* ; Hemorrhage ; Humans ; Male ; Needles ; Pancreatic Neoplasms ; Pancreatitis ; Retrospective Studies ; Stents

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult to perform in patients with a Billroth II anastomosis due to the anatomical alterations. This study evaluated retrospectively the efficacy and safety of endoscopic balloon dilatation after a partial infundibulotomy with a needle knife in patients who had undergone a Billroth II operation. METHODS: Between January 1, 2004 and December 31, 2005, 11 patients, who had undergone a prior Billroth II gastrectomy, underwent ERCP because of a suspicion of pancreatobiliary diseases. Infundibulotomy was performed using a needle knife sphincterotome. After a partial infundibulotomy, a dilation balloon was passed over a prepositioned guidewire and placed in the biliary orifice. Under endoscopic and fluoroscopic control, the balloon was then inflated with diluted contrast over a period of 1 to 2 minutes. RESULTS: A total of 10 patients (7 male and 3 female) were enrolled in this study. Eight had common bile duct stones, 1 bile duct cancer, and 1 pancreatic cancer. The common bile duct was dilated by a balloon. The calculi were removed in 6 patients, and a common bile duct stent was implanted in two cases via endoscopy. No complications such as acute pancreatitis or apparent infections of the biliary tracts were encountered in these cases except for mild fever, temporary high serum levels of aminotransferase and amylase after ERCP in 3 cases. No severe bleeding or perforation occurred in patients undergoing balloon dilatation. CONCLUSIONS: An infundibulotomy with balloon dilatation is a valuable alternative to endoscopic sphinterotomy in the treatment of patients with bile duct diseases, who have undergone prior Billroth II gastrectomies.
Amylases ; Bile Duct Diseases ; Bile Duct Neoplasms ; Biliary Tract ; Calculi ; Cholangiopancreatography, Endoscopic Retrograde ; Common Bile Duct ; Dilatation* ; Endoscopy ; Fever ; Gastrectomy ; Gastroenterostomy* ; Hemorrhage ; Humans ; Male ; Needles ; Pancreatic Neoplasms ; Pancreatitis ; Retrospective Studies ; Stents

BACKGROUND: Bile examination is believed to be the most precise method for detecting Clonorchis sinensis (CS) eggs. We carried out bile examination to evaluate infestation state of CS in patients with pancreatobiliary diseases in Ulsan, known as an endemic area of CS infestation. METHODS: We examined CS eggs in bile in three hundreds and nine patients with pancreatobiliary diseases. The bile was obtained from endoscopic nasobiliary or percutaneous transhepatic biliary drainage tubes. RESULTS: The overall egg positive rate was 27.5% (35.3% in male, 17.6% in female). The egg positive rate was not significantly different according to the age group: 20.0% in thirties, 26.7% in forties, 24.2% in fifties, 29.9% in sixties, 36.2% in seventies and 16.7% in eighties or more. The egg positive rate according to the disease, except CS cholangitis, was not also statistically different: 32.6% in bile duct cancer, 38.5% in gallbladder cancer, 11.1% in ampulla of Vater cancer, 24.0% in pancreatic cancer, 26.4% in gallstone diseases and 12.5% in the reminder. The location of gallstone and whether CS related diseases or CS unrelated diseases did not affect the egg positive rates. The egg positive rate in patients with normal radiological findings including cholangiography was 17.0%. CONCLUSION: This result shows that regardless of age, sex, and sorts of diseases, the infestation rate of CS was very high. On the basis of our results, it is therefore presumes that clonorchiasis is still endemic disease in Korea.
Ampulla of Vater ; Bile Duct Neoplasms ; Bile* ; Biliary Tract Diseases ; Cholangiography ; Cholangitis ; Clonorchiasis ; Clonorchis sinensis* ; Drainage ; Eggs ; Endemic Diseases ; Gallbladder Neoplasms ; Gallstones ; Humans ; Korea ; Male ; Ovum ; Pancreatic Diseases ; Pancreatic Neoplasms ; Ulsan*

As recent advances in chemotherapy and surgical treatment have improved outcomes in patients with biliary cancers, the search for an optimal strategy for relief of their obstructive jaundice has become even more important. Without satisfactory relief of biliary obstruction, many patients would be ineligible for treatment. We review all prospective randomized trials and recent retrospective non-randomized studies for evidence that would support such a strategy. For distal malignant biliary obstruction, an optimal strategy would be insertion of metallic stents either endoscopically or percutaneously. Evidence shows that a metallic stent inserted percutaneously has better outcomes than plastic stents inserted endoscopically. For malignant hilar obstruction, percutaneous biliary drainage with or without metallic stents is preferred.
Bile Duct Neoplasms/pathology/surgery ; Biliary Tract Diseases/pathology/*surgery ; Cholangiocarcinoma/pathology/surgery ; Decompression, Surgical ; Drainage/methods ; Endoscopy ; *Evidence-Based Medicine ; Hepatic Duct, Common ; Humans ; Jaundice, Obstructive/pathology/*surgery ; Klatskin's Tumor/pathology/surgery ; Stents

The aim of percutaneous transhepatic biliary drainage(PTBD) is to decrease serum bilirubin level and promoteliver function in patient with biliary tract disease, especially obstruction by malignant disese. But somepatients showed persistent high serum bilirubin level or higher than pre-PTBD level. Percutaneous transhepaticbiliary drainage was performed in 341 patients of obstructive jaundice for 5 years from July, 1981 to July, 1986at departement of radiology, Seoul Natinal University Hospital. Follow up check of the serum bilibrubin level waspossible in 188 patients. Among them the authors analysed 32 patients who showed persistent high serum bilirubinlevel after PTBD. The results were as follows: 1. The male to female ratio was 3.4:1 and the age ranged from 33 to 75. 2. The causes of obstructive jaundice included 30 malignant diseases and 2 benign diseases. Malignant diseasewere 16 cases of bile duct carcinoma, 7 cases of pancreatic cancer and 7 cases of matastasis from stomach, colonand uterine cervix. Benign disease were 1 cases of common hepatic duct stone and 1 case of intrahepatic ductstones. 3. The msot common level of obstruction was trifurcation in 17 cases. 4. The most common indication ofPTBD was palliative drainage of obstruciton secondary to malignant tumor in 28 cases. 5. Change of serujmbilirubin level ratio(post-PTBD level) was 1.28, 1.22, 1.38, 1.51 in serial period of 1–3 days, 4–6 days, 1–2 week 2–3 week after PTBD. 6. Causes of persistent high serum bilirubin level after PTBD were 12 cases of partialdrainage of intrahepatic bile, 13 cases of hepatic dysfunction including 9 cases of metastatic nodule, 2 cases ofbiliary cirrhosis, 2 cases of multiple liver abscess, and 7 cases of poor function of cather including 4 cases ofhemobilia, 1 case of multiple intrahepatic stones, pyobilia and intraheptic Clonorchis sinensis.
Bile ; Bile Ducts ; Biliary Tract Diseases ; Bilirubin ; Cervix Uteri ; Clonorchis sinensis ; Drainage ; Female ; Fibrosis ; Follow-Up Studies ; Hepatic Duct, Common ; Humans ; Jaundice, Obstructive ; Liver Abscess ; Male ; Pancreatic Neoplasms ; Seoul ; Stomach

Fourtyone patients fo gallbladder and bile duct diseases were studied clinically and sonographically.Tweentynine (Seventyone percent) patients were distributed between age fourty to fiftynine and male to femaleratio was 1:1.4. The order of frequency of biliary tract disease was cholelithiasis, acalculous cholecystitis, CBDstone and CBD cancer. Sonographic findings of cholelithiasis were strong echo with posterior shadowing, faintinternal echoes without shadowing, gallbladder wall thickneing and anechoicity of the gallbladder wall. Instead ofsmall proportion of gallbladder distension and wall anechoicity, faint internal echoes without shadowing were seenin ten of nineteen cases of cholelithiasis. On choledocholithiasis, meniscus sign at the junction of the stone andgallbladder wall was identified in most cases and was helpful to differentiation stone from malignancy. The degreeof CBD dilatation was more severe in malignancy than in CBD stones and ascaris in CBD. Sonographic examination wasuseful in detection of gallbladder and bilicary tree pathology and the cause of biliary tract obstruction could beidentified.
Acalculous Cholecystitis ; Ascaris ; Bile Duct Diseases ; Biliary Tract Diseases ; Biliary Tract ; Choledocholithiasis ; Cholelithiasis ; Dilatation ; Gallbladder ; Humans ; Male ; Pathology ; Shadowing (Histology) ; Trees ; Ultrasonography

The feasibility of using computed tomography (CT) to identify the common bile duct (CBD) and comparison with ultrasonography (US) results were evaluated in normal beagle dogs and dogs without hepatobiliary and pancreatic diseases. In addition, CBD diameters were obtained from CT at the level of the porta hepatis and the duodenal papilla level in dogs with underlying diseases that may cause cholestasis. US is a useful modality in the estimation of gallbladder volume because ejection fraction and CBD diameter from US were not significantly different from those of CT. The normal biliary tract was visible on CT images in 68% of the normal dog group. CBD diameter was not over 3 mm and 3.5 mm at the porta hepatis and duodenal papilla levels, respectively in normal dogs weighing less than 15 kg. Dogs suspected to have cholestasis associated with hepatobiliary or pancreatic diseases had significantly larger CBD than that in normal dogs.
Animals ; Biliary Tract ; Cholestasis ; Common Bile Duct ; Dogs ; Gallbladder ; Pancreatic Diseases ; Ultrasonography