Korean autoimmune pancreatitis (AIP) criteria 2007 was aimed to diagnose the wide spectrum of AIP with high sensitivity. The most crucial issue when caring for patients with suspected AIP is to differentiate AIP from pancreatic cancer. Pancreatic cancer can be distinguished from AIP by pancreatic imaging, measurement of serum IgG4 levels, endoscopic ultrasound guided fine needle aspiration and trucut biopsy, and steroid trial. Autoimmune pancreatitis is a rare systemic fibroinflammatory disease which can affect not only the pancreas, but also a variety of organs such as the bile ducts, salivary glands, retroperitoneum, and lymph nodes. Organs affected by AIP have a lymphoplasmacytic infiltrate rich in IgG4-positive cells. This inflammatory process responds dramatically to oral steroid therapy. Granulocytic epithelial lesion (GEL) positive AIP patients differ from GEL negative AIP patients in clinical features such as equal gender ratio, younger mean age, no increase in serum IgG4, no association with extrapancreatic involvement, no relapse, and frequent association with inflammatory bowel disease. Further investigation is needed to clarify the pathogenic mechanisms including more definite serological markers for theses two entities.
Autoimmune Diseases/*diagnosis/pathology/ultrasonography ; Common Bile Duct/radiography ; Fibrosis/pathology ; Humans ; Immunoglobulin G/blood ; Pancreatitis/*diagnosis/pathology/ultrasonography ; Salivary Glands/pathology

No abstract available.
Aged ; Common Bile Duct/*pathology ; Common Bile Duct Diseases/*diagnosis/pathology/ultrasonography ; Diagnosis, Differential ; Female ; Humans ; Hyperplasia ; Magnetic Resonance Imaging ; Polyps/*pathology ; Positron-Emission Tomography ; Tomography, X-Ray Computed

PURPOSE: Choledochal cyst is a cystic dilatation of common bile duct. Although the etiology is presently uncertain, anomalous pancreaticobiliary ductal union (APBDU) is thought to be a major etiology of choledochal cyst. In this study, we analyzed the clinical and anatomical characteristics and pathologies of patients diagnosed with choledochal cyst in a single institute for 25 years. METHODS: A total of 113 patients, diagnosed with choledochal cyst and who received an operation in Severance Children's Hospital from January 1988 to May 2013, were included. Medical records were reviewed, including clinical and demographic data, surgical procedures. Abdominal ultrasonography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography were used as diagnostic tools for evaluation and classification of choledochal cyst and the presence of anomalous pancreaticobiliary ductal union. Todani's classification, and relationship between APBDU and surgical pathology. RESULTS: Among 113 patients, 77 patients (68.1%) presented symptoms such as hepatitis, pancreatitis and/or cholecystitis. Eighty three patients (73.5%) had APBDU, and 94 patients (83.2%) showed inflammatory pathologic changes. APBDU, pathologic inflammation, and serological abnormalities such as hepatitis or pancreatitis showed a statistically significant correlation to one another. CONCLUSION: APBDU is thought to be one of the etiologic factors of choledochal cyst. It is related to the inflammatory changes in bile duct that can lead to the cystic dilatation.
Bile Ducts* ; Child ; Cholangiography ; Cholangiopancreatography, Magnetic Resonance ; Cholecystitis ; Choledochal Cyst* ; Classification ; Common Bile Duct ; Dilatation ; Hepatitis ; Humans ; Inflammation* ; Medical Records ; Pancreatitis ; Pathology ; Pathology, Surgical ; Ultrasonography

We report here on a case of extrahepatic biliary cystadenoma arising from the common hepatic duct. A 42-year-old woman was evaluated by us to find the cause of her jaundice. Ultrasonography and CT showed a cystic dilatation of the common hepatic duct and also marked dilatation of the intrahepatic duct. Direct cholangiography demonstrated a large filling defect between the left hepatic duct and the common hepatic duct; dilatation of the intrahepatic duct was also demonstrated. Following excision of the cystic mass, it was pathologically confirmed as a unilocular biliary mucinous cystadenoma arising from the common hepatic duct.
Adult ; Bile Duct Neoplasms/*diagnosis ; Cholangiopancreatography, Magnetic Resonance ; Choledochal Cyst/*diagnosis ; Cystadenoma/*diagnosis ; Diagnosis, Differential ; Female ; Hepatic Duct, Common/*pathology/radiography/ultrasonography ; Humans ; Tomography, X-Ray Computed ; Ultrasonography, Interventional

A laparoscopic cholecystectomy has been accepted as one of the methods of treatment for patients with gallbladder(GB) pathology. Occasionally some cases can be diagnosed as cancer of the gallbladder incidentally after a laparoscopic cholecystectomy. We did 855 laparoscopic cholecystectomies from September 1991 to July 1996 and found 9 GB cancer patients after the operation. Most of the patients with GB cancer have a poor prognosis, but recently there have been some reports with good prognoses in this group of patients. The incidence of incidental GB cancer in laparoscopically resected GB specimens was 1.1% (9/855). The age distribution was between 44 and 72 yrs. Among the 9 cancer patients, 6 patients were found to have a GB mass as a result of the preoperative ultrasound examination. Four patients had mucosa-confined cancer and did not undergo any further treatment. One patient had mucosa confined cancer with a residual tumor in the cystic duct resection margin and underwent segmental resection of the liver (IVa & V) and segmental resection of the common bile duct, including dissection of the pericholedochal lymph node. The other four patients had advanced GB cancer with subserosal invasion. One patient underwent segmental resection of the liver (IVa & V) and segmental resection of the common bile duct, including dissection of the pericholedochal lymph node, and the other patient received a pericholedochal lymph node dissection only. The follow-up period ranged from 39 months to 3 months. Only one patient, who had mucosa-confined cancer with cystic duct invasion, died from lung metastasis with local recurrence of the midclavicular trocar site at 16 months after the laparoscopic cholecystectomy, but the other 8 patients have been doing well until now. We recommend a habit of opening the gallbladder, examining the gross pathologic features, and performing a frozen-section examination in patients where GB cancer is suspected. During that procedure, a careful isolation technique (careful dissection and delivery of the specimen in vinyl bag is vital) for preventing tumor implantation.
Age Distribution ; Cholecystectomy, Laparoscopic* ; Common Bile Duct ; Cystic Duct ; Follow-Up Studies ; Gallbladder Neoplasms* ; Gallbladder* ; Humans ; Incidence ; Liver ; Lung ; Lymph Node Excision ; Lymph Nodes ; Mucous Membrane ; Neoplasm Metastasis ; Neoplasm, Residual ; Pathology ; Prognosis ; Recurrence ; Surgical Instruments ; Ultrasonography

BACKGROUND/AIMS: Laparoscopic cholecystectomy(LC) has become the new therapeutic gold standard in uncomplicated symptomatic gallbladder stone. However, some patients with gallstones may be associated with bile duct stones or other biliary pathology. LC is not ideal for removal and evaluation of biliary duct stones even with advocated techniques. Although ERCP is the best way to demonstrate the biliary tree, ERCP is an invasive procedure that may causes complications. The aim of this study was to predict the neeessity for ERCP and to determine the indication of ERCP before LC using noninvasive methods of biliary tree associated liver biochemistry(LB) parameters and sonography. METHODS: 270 symptomatic gallbladder stone patients were studied by both sonography and LB including total bilirubin, alkaline phophatase, gamma-glutamyltransferase and amylase. All patients were performd ERCP for evaluation of biliary tree pathology, Patients who were already found to have either tumors or bile duct stones on sonography were excluded. Patients were classified into normal and dilated biliary tree groups by sonographic findings, normal and abnormal LB groups, negative and positive ERCP groups. Positive ERCP were defined by bile duct stones, tumors, stricture and idiopathic common bile duct dilatation over 11 mm. RESULTS: 1) There were positive ERCP findings in 30.4% of all patients. 2) The male to female ratio was 1:2, and the patients of positive ERCP group (58.9 +/- 12.0) were significantly )p=0.000) older than negative group (52.7 +/- 13.1). 3) There was bile duct dilatation in 39.3% of patients by sonography. Bile duct dilatation on sonography had an 66.0% positive predictability, 85.3% sensitivity and 80.6% specificity for ductal pathology on ERCP. 4) There was abnormal LB in 53.0% of patients. A single abnormal LB equated to a 46.2% positive predictablity, 80.5% sensitivity and 59.0% specificity for ductal pathology on ERCP. 5) In patients with both normal sonography and LB, 96.0% of patients had a negative ERCP study. CONCLUSION: ERCP is not necessary before LC for patients with symptomatic gallbladder stones who have both a normal biliary tree on sonography and normal LB. But, a patient with either a dilated bile duct on sonography of an abnormal LB does require ERCP study.
Amylases ; Bile Ducts ; Biliary Tract ; Bilirubin ; Cholangiopancreatography, Endoscopic Retrograde* ; Cholecystectomy ; Common Bile Duct ; Constriction, Pathologic ; Dilatation ; Female ; Gallbladder ; Gallstones ; gamma-Glutamyltransferase ; Humans ; Laparoscopy ; Liver ; Male ; Pathology ; Sensitivity and Specificity ; Ultrasonography

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate modality in diagnosis of choledocholithiasis. However, it carries some complications. Endoscopic ultrasonography (EUS) is less invasive than ERCP and used for the diagnosis of choledocholithiasis. Recent studies showed that a usefulness of EUS for the diagnosis of small choledocholithiasis without common bile duct (CBD) dilatation. For such a reason, ERCP is being replaced by EUS in the diagnosis of bile duct stones. The aim of this study was to investigate the accuracy of EUS for the diagnosis of choledocholithiasis without CBD dilatation. METHODS: A total of 66 patients with suspected choledocholithiasis without CBD dilatation were enrolled. EUS were performed in all cases within 48 hours after computed tomography (CT) or ultrasonography (US). Final diagnosis was obtained by ERCP or clinical course (minimum 6 months follow-up). We analyzed the accuracy of US, CT, and EUS, respectively. RESULTS: CT and US were performed in 51 and 15 cases, respectively. CBD stones were detected in 23 (35%) patients by ERCP. EUS showed 100% sensitivity, 95% specificity, 92% positive predictive value, and 100% negative predictive value for identifying CBD stones. CT or US showed 26%, 93%, 67%, and 70%, respectively. There were no EUS-related complications. CONCLUSIONS: EUS was more effective than CT or US and as accurate as ERCP for the diagnosis of small choledocholithiasis without CBD dilatation. Thus, EUS may help to avoid unnecessary diagnostic ERCP and its complication.
Adult ; Aged ; Aged, 80 and over ; Choledocholithiasis/pathology/*ultrasonography ; Common Bile Duct Diseases/diagnosis ; Diagnosis, Differential ; Dilatation, Pathologic/diagnosis ; *Endosonography ; Female ; Gallstones/ultrasonography ; Humans ; Male ; Middle Aged ; Sensitivity and Specificity ; Tomography, X-Ray Computed

IgG4-related systemic diseases are characterized by a diffuse or mass forming inflammatory reaction rich in lymphocytes and IgG4-positive plasma cells (lymphoplasmacytic infiltration), fibrosclerosis of variable organs and obliterative phlebitis. They usually involve various organs including the pancreas, bile duct, gallbladder, salivary gland, retroperitoneum, kidney, lung, and prostate. However, most of them are accompanied by autoimmune pancreatitis, and good response to steroid treatment is one of the hallmarks of this disease. We report a case of an 67-year-old man with IgG4 associated sclerosing cholangitis, who was diagnosed by endoscopic retrograde cholangiopancreatography and successfully treated with steroid therapy.
Aged ; Anti-Inflammatory Agents/therapeutic use ; Autoimmune Diseases/complications/diagnosis ; Bile Ducts, Intrahepatic/pathology/ultrasonography ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis, Sclerosing/complications/*diagnosis/drug therapy ; Common Bile Duct/pathology/ultrasonography ; Humans ; Immunoglobulin G/*blood ; Immunohistochemistry ; Male ; Pancreatitis/complications/diagnosis ; Prednisolone/therapeutic use ; Tomography, X-Ray Computed