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ERCP showing a dilated (11 mm) irregular common bile duct, intrahepatic duct strictures, and a normal pancreatogram. (Endoscope, Olympus TJF10.)
Source publication
Four patients with acquired immunodeficiency syndrome (AIDS) (CDC group IV) were investigated for biliary disease because of the presence of both severe upper abdominal pain and raised levels of serum alkaline phosphatase. None was clinically jaundiced. Upper abdominal ultrasound was abnormal in three. All had endoscopic retrograde cholangiographic...
Context in source publication
Context 1
... echo pattern, and a normal biliary tree. As pain was worsening and the patient's quality of life was reasonable despite the numerous HIV-related complications, a diagnostic ERCP was performed. It showed gastric Kaposi's sarcoma, a midly dilated and irregular common bile duct above a narrowed papilla, and multiple intrahepatic duct strictures (Fig. 3). An endoscopic sphincterotomy was performed and provided almost complete pain relief, with paracetamol only rarely being required for mild upper abdominal discomfort afterwards. The liver function test, however, remained largely unchanged. Duodenal biopsy specimens showed a mild chronic inflammation, but culture and histology J . F. ...
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Citations
... The biliary system provides a reservoir for the Cryptosporidium parasite and cryptosporidiosis of the pancreato-biliary system is well-recognised in patients who are immune-compromised, especially in those with T-cell immune deficiency [2]. Sclerosing cholangitis as a result is well-described [3][4][5][6]. Cryptosporidium enteritis in solid organ transplant recipients has previously been associated with elevated tacrolimus concentrations [7] and there also exists one report of C. parvuminduced sclerosing cholangitis in an adult renal transplant patient taking tacrolimus [8]. To the best of our knowledge, this is the first report of C. hominis associated with use of tacrolimus in a patient with nephrotic syndrome. ...
Introduction:
Cryptosporidium infection is known to cause hepato-biliary involvement, mainly in association with T-cell immune deficiency. Hepato-biliary involvement in association with milder immunosuppression is less well described. We describe the first case, to our knowledge, of Cryptosporidium hominis hepato-biliary infection associated with tacrolimus in a patient with nephrotic syndrome.
Case presentation:
A 14 year old girl who had been on tacrolimus for nephrotic syndrome presented with diarrhea due to C. hominis. Nineteen days after her initial presentation she attended hospital with abdominal pain and deranged liver function tests. An ultrasound scan showed a thickened gall bladder. Her symptoms settled and her liver function tests returned to normal after treatment with nitazoxanide.
Conclusion:
Cryptosporidium should be considered in the differential diagnosis of both diarrhea and hepato-biliary symptoms and abnormal liver function tests, even in the presence of relatively mild immunosuppression. Nitazoxanide was an effective treatment in this case.
... Although less commonly reported than gastrointestinal infections, extra-gastrointestinal cryptosporidiosis does occur, and can affect both immunocompetent (Westrope and Acharya, 2001) and, with greater frequency, immunocompromised, -suppressed or -deficient individuals (Bonacini, 1992;Dowsett et al., 1988;Vakil et al., 1996). Such infections can be categorized as pulmonary (Clavel et al., 1996) as well as biliary or pancreatic (Forbes et al., 1993;Goodwin, 1991;Vakil et al., 1996), and often Cryptic Parasite Revealed appear to result from the systemic spread of an initial infection from the gastrointestinal tract (e.g. ...
Onchocerciasis has historically been one of the leading causes of infectious blindness worldwide. It is endemic to tropical regions both in Africa and Latin America and in the Yemen. In Latin America, it is found in 13 foci located in 6 different countries. The epidemiologically most important focus of onchocerciasis in the Americas is located in a region spanning the border between Guatemala and Mexico. However, the Amazonian focus straddling the border of Venezuela and Brazil is larger in overall area because the Yanomami populations are scattered over a very large geographical region.
... Although less commonly reported than gastrointestinal infections, extra-gastrointestinal cryptosporidiosis does occur, and can affect both immunocompetent (Westrope and Acharya, 2001) and, with greater fre- quency, immunocompromised, -suppressed or -deficient individuals (Bonacini, 1992;Dowsett et al., 1988;Vakil et al., 1996). Such infections can be categorized as pulmonary ( Clavel et al., 1996) as well as biliary or pancreatic ( Forbes et al., 1993;Goodwin, 1991;Vakil et al., 1996), and often appear to result from the systemic spread of an initial infection from the gastrointestinal tract (e.g. ...
Cryptosporidium is an important genus of parasitic protozoa of humans and other vertebrates and is a major cause of intestinal disease globally. Unlike many common causes of infectious enteritis, there are no widely available, effective vaccine or drug-based intervention strategies for Cryptosporidium, and control is focused mainly on prevention. This approach is particularly deficient for infections of severely immunocompromised and/or suppressed, the elderly or malnourished people. However, cryptosporidiosis also presents a significant burden on immunocompetent individuals, and can, for example have lasting effects on the physical and mental development of children infected at an early age. In the last few decades, our understanding of Cryptosporidium has expanded significantly in numerous areas, including the parasite life-cycle, the processes of excystation, cellular invasion and reproduction, and the interplay between parasite and host. Nonetheless, despite extensive research, many aspects of the biology of Cryptosporidium remain unknown, and treatment and control are challenging. Here, we review the current state of knowledge of Cryptosporidium, with a focus on major advances arising from the recently completed genome sequences of the two species of greatest relevance in humans, namely Cryptosporidium hominis and Cryptosporidium parvum. In addition, we discuss the potential of next-generation sequencing technologies, new advances in in silico analyses and progress in in vitro culturing systems to bridge these gaps and to lead toward effective treatment and control of cryptosporidiosis.
... At an advanced stage of AIDS (CD4 counts typically !100/mm 3 ), a combination of biliary pain, elevation of serum alkaline phosphatase and gross bile duct anomalies may occur [91][92][93][94][95][96][97]. In 25% of these patients, a smooth stenosis of the terminal portion of the common bile duct, socalled papillary stenosis, is observed, while the intrahepatic bile ducts are dilated but regular [97]. ...
Bile ducts are supplied with blood exclusively via hepatic arteries. Obstruction of large arteries is rapidly compensated for by the opening of preexisting intrahepatic or transcapsular collateral arteries, which prevents ischemic damage. Ischemic bile duct injury may occur when small hepatic arteries or the peribiliary vascular plexus are injured, or when all possible arterial blood supplies are interrupted, as is the case in transplanted liver with hepatic artery thrombosis. Most causes of bile duct ischemia are iatrogenic. Systemic diseases involving small hepatic arteries may also be implicated. Depending on the extent and velocity of the arterial obstructive process, ischemic cholangiopathy may present as acute formation of biliary casts, bile duct necrosis, or chronic disease resembling primary sclerosing cholangitis. In many patients, correction of arterial obstruction is not possible. When biliary drainage or reconstruction is not possible or has failed, liver transplantation is the only means of providing potential cure.
In the summer of 1981 reports of 5 cases of Pneumocystis carinii pneumonia (PCP) and 26 cases of Kaposi’s sarcoma (KS) amongst homosexual men in Los Angeles, California and New York represented the first description of the acquired immune deficiency syndrome (AIDS) (Friedman-Kien et al, 1981, 1982; Gottlieb et al, 1981a,b). It was not realized at this time, of course, that the causative agent was already present in persons in four other continents. The virus, variously named, was first discovered in 1983 (Barré-Sinoussi et al, 1983; Gallo et al, 1983). The first antibody tests were developed in 1984. In 1986 the sub-committee of the International Committee for the Taxonomy of Viruses suggested that the generic name for the virus should be the human immunodeficiency virus (HIV) (Biberfield et al, 1987). By this time the CD4 antigen had been identified as the cellular receptor for HIV and the first trials of the antiviral agent zidovudine were demonstrating efficacy in patients with symptomatic disease (Fischl et al, 1987).
Gastrointestinal disease occurs in the majority of patients with the acquired immunodeficiency syndrome (AIDS). Opportunistic gut infection and neoplasia occur throughout the gut. The differential diagnosis of HIV-related gastrointestinal symptoms is large and includes tumours and a variety of opportunistic infections. Multiple pathology is common. Investigation of gastrointestinal symptoms is important as many pathogens will respond to specific therapy, although relapse is common and long-term treatment may be necessary. Where specific treatment for gastrointestinal disease is not available or has been unsuccessful it is always possible to palliate patients’ symptoms and improve their quality of life. This chapter aims to describe some of the more common gastrointestinal problems that physicians are likely to encounter and to provide guidelines for investigation and management.
Patients infected with the human immunodeficiency virus (HIV) frequently present dysfunction related to hepatobiliary involvement. The more common clinic presentation are the alterations of the laboratorial tests, either reflecting hepatocellular damage (elevation of ALT and AST) or cholestasis (elevation of the alkaline fosfatase and gamma-GT). These can be due to primary or secondary infections of the liver and biliary system, to neoplastic involvement, or to alterations of the hepatic metabolism as a direct or indirect consequence of the HIV infection. AIDS cholangiopathy is a clinical-pathological entity characterized morphologically by alterations in the biliary system of individuals infected with HIV in severe immunosuppression (generally with CD4 lymphocytes countings inferior to 200/mm3), with serious deterioration of general state and with coexistent infection or neoplasia. It occurs approximately in 5% of AIDS patients. The patients usually present with pain in the right upper abdominal quadrant and accentuated elevation of the alkaline fosfatase and, sometimes, fever. Diagnosis should be suspected by the presence of biliary tree dilation in ultrassonography and is supported by characteristic aspects in endoscopic retrograde cholangiopancreatography (ERCP). We review some aspects of this entity regarding the pathogeny, clinical presentation, diagnosis, cholangiographic patterns and treatment.
Cholangitis is an infection of the biliary ductal system. It is a result of bacterial infection superimposed on partial or complete obstruction of the biliary system. The original description of cholangitis, by Charcot in 1877 [1], alluded to inflammation and the symptoms now known as “Charcot’s triad” (intermittent chills and fever, jaundice and abdominal pain). In clinical practice, the term “cholangitis” is used to refer to the signs and symptoms produced by bacterial inflammation of the biliary duct system, without regard to the presence or absence of inflammatory changes within the walls of the bile ducts or the parenchyma of the liver. Bacteria can be present within the biliary tract (bacterbilia) without clinical symptoms and the bile of asymptomatic patients can harbor many bacteria if the biliary tree is otherwise normal. Thus, bacteria in bile, increased biliary pressure, and invasion of bacteria into the bile ducts and liver tissue are all important in the development of cholangitis
