Tag: Bile duct

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Ailmemts & Remedies

Cholangitis

Definition:
Cholangitis is an infection of the common bile duct, the tube that carries bile from the liver to the gallbladder and intestines. Bile is a liquid made by the liver that helps digest food.

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Cholangitis can be life-threatening, and is regarded as a medical emergency. Characteristic symptoms include yellow discoloration of the skin or whites of the eyes, fever, abdominal pain, and in severe cases, low blood pressure and confusion. Initial treatment is with intravenous fluids and antibiotics, but there is often an underlying problem (such as gallstones or narrowing in the bile duct) for which further tests and treatments may be necessary, usually in the form of endoscopy to relieve obstruction of the bile duct.
Symptoms:
The following symptoms may occur:

*Pain on the upper right side or upper middle part of the abdomen. It may also be felt in the back or below the right shoulder blade. The pain may come and go and feel sharp, cramp-like, or dull.

*Fever and chills

*Dark urine and clay-colored stools

*Nausea and vomiting

*Yellowing of the skin (jaundice), which may come and go
Physical examination findings typically include jaundice and right upper quadrant tenderness.Charcot’s triad is a set of three common findings in cholangitis: abdominal pain, jaundice, and fever. This was assumed in the past to be present in 50–70% of cases, although more recently the frequency has been reported as 15–20%.Reynolds’ pentad includes the findings of Charcot’s triad with the presence of septic shock and mental confusion. This combination of symptoms indicates worsening of the condition and the development of sepsis, and is seen less commonly still.

In the elderly, the presentation may be atypical; they may directly collapse due to septicemia without first showing typical features. Those with an indwelling stent in the bile duct (see below) may not develop jaundice.

Causes:
Cholangitis is most often caused by a bacterial infection. This can occur when the duct is blocked by something, such as a gallstone or tumor. The infection causing this condition may also spread to the liver.

Bile duct obstruction, which is usually present in acute cholangitis, is generally due to gallstones. 10–30% of cases, however, are due to other causes such as benign stricturing (narrowing of the bile duct without an underlying tumor), postoperative damage or an altered structure of the bile ducts such as narrowing at the site of an anastomosis (surgical connection), various tumors (cancer of the bile duct, gallbladder cancer, cancer of the ampulla of Vater, pancreatic cancer, cancer of the duodenum), anaerobic organisms such as Clostridium and Bacteroides (especially in the elderly and those who have undergone previous surgery of the biliary system). Parasites which may infect the liver and bile ducts may cause cholangitis; these include the roundworm Ascaris lumbricoides and the liver flukes Clonorchis sinensis, Opisthorchis viverrini and Opisthorchis felineus. In people with AIDS, a large number of opportunistic organisms has been known to cause AIDS cholangiopathy, but the risk has rapidly diminished since the introduction of effective AIDS treatment. Cholangitis may also complicate medical procedures involving the bile duct, especially ERCP. To prevent this, it is recommended that those undergoing ERCP for any indication receive prophylactic (preventative) antibiotics.

The presence of a permanent biliary stent (e.g. in pancreatic cancer) slightly increases the risk of cholangitis, but stents of this type are often needed to keep the bile duct patent under outside pressure

Diagnosis:
Routine blood tests show features of acute inflammation (raised white blood cell count and elevated C-reactive protein level), and usually abnormal liver function tests (LFTs). In most cases the LFTs will be consistent with obstruction: raised bilirubin, alkaline phosphatase and ?-glutamyl transpeptidase. In the early stages, however, pressure on the liver cells may be the main feature and the tests will resemble those in hepatitis, with elevations in alanine transaminase and aspartate transaminase.

Blood cultures are often performed in people with fever and evidence of acute infection. These yield the bacteria causing the infection in 36% of cases, usually after 24–48 hours of incubation. Bile, too, may be sent for culture during ERCP (see below). The most common bacteria linked to ascending cholangitis are gram-negative bacilli: Escherichia coli (25–50%), Klebsiella (15–20%) and Enterobacter (5–10%). Of the gram-positive cocci, Enterococcus causes 10–20%.

You may have the following tests to look for blockages:

*Abdominal ultrasound

*Endoscopic retrograde cholangiopancreatography (ERCP)

*Magnetic resonance cholangiopancreatography (MRCP)

*Percutaneous transhepatic cholangiogram (PTCA)

*You may also have the following blood tests:

#Bilirubin level
#Liver enzyme levels
#Liver function tests
#White blood count (WBC)
Treatment:
Quick diagnosis and treatment are very important.Antibiotics to cure infection is the first treatment done in most cases. ERCP or other surgical procedure is done when the patient is stable.Patients who are very ill or are quickly getting worse may need surgery right away.

Cholangitis requires admission to hospital. Intravenous fluids are administered, especially if the blood pressure is low, and antibiotics are commenced. Empirical treatment with broad-spectrum antibiotics is usually necessary until it is known for certain which pathogen is causing the infection, and to which antibiotics it is sensitive. Combinations of penicillins and aminoglycosides are widely used, although ciprofloxacin has been shown to be effective in most cases, and may be preferred to aminoglycosides because of fewer side effects. Metronidazole is often added to specifically treat the anaerobic pathogens, especially in those who are very ill or at risk of anaerobic infections. Antibiotics are continued for 7–10 days. Drugs that increase the blood pressure (vasopressors) may also be required to counter the low blood pressure.
Prognosis:
Acute cholangitis carries a significant risk of death, the leading cause being irreversible shock with multiple organ failure (a possible complication of severe infections). Improvements in diagnosis and treatment have led to a reduction in mortality: before 1980, the mortality rate was greater than 50%, but after 1980 it was 10–30%. Patients with signs of multiple organ failure are likely to die unless they undergo early biliary drainage and treatment with systemic antibiotics. Other causes of death following severe cholangitis include heart failure and pneumonia.

Risk Factors:
Risk factors include a previous history of gallstones, sclerosing cholangitis, HIV, narrowing of the common bile duct, and, rarely, travel to countries where you might catch a worm or parasite infection.

Risk factors indicating an increased risk of death include older age, female gender, a history of liver cirrhosis, biliary narrowing due to cancer, acute renal failure and the presence of liver abscesses. Complications following severe cholangitis include renal failure, respiratory failure (inability of the respiratory system to oxygenate blood and/or eliminate carbon dioxide), cardiac arrhythmia, wound infection, pneumonia, gastrointestinal bleeding and myocardial ischemia (lack of blood flow to the heart, leading to heart attacks).

Prevention:
Treatment of gallstones, tumors, and infestations of parasites may reduce the risk for some people. A metal or plastic stent that is placed in the bile system may be needed to prevent the infection from returning.
Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.
Resources:
http://www.nlm.nih.gov/medlineplus/ency/article/000290.htm
http://en.wikipedia.org/wiki/Ascending_cholangitis

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Ailmemts & Remedies Pediatric

Biliary Atresia

DEfinition:
Biliary atresia is a rare condition in newborn infants in which the common bile duct(that carry a liquid called bile from the liver to the gallbladder) between the liver and the small intestine is blocked or absent. If unrecognized, the condition leads to liver failure — but not kernicterus, as the liver is still able to conjugate bilirubin, and conjugated bilirubin is unable to cross the blood-brain barrier. The cause of the condition is unknown. The only effective treatments are certain surgeries such as the kasai procedure, or liver transplantation.

.….You may click to see the picture

Biliary atresia is a very rare disorder. About one in 10,000 to 20,000 babies in the U.S are affected every year. Biliary atresia seems to affect girls slightly more often than boys. Within the same family, it is common for only one child in a pair of twins or only one child within the same family to have it. Asians and African-Americans are affected more frequently than Caucasians. There does not appear to be any link to medications or immunizations given immediately before or during pregnancy.

This is now effective surgery which can relieve symptoms in most cases. Liver transplant is also an option, and as a result, survival rates are now above 90 per cent.

Causes & b Risk Factors:
Biliary atresia is due to a progressive fibrosis or scarring of the bile ducts responsible for draining bile from the liver, which eventually leads to atresia or loss of the biliary system. It’s not clear how or why this occurs, and many factors may be involved. It may be due to a problem in the developing embryo (10 to 20 per cent – other congenital abnormalities may also be present) or around the time of birth or shortly afterwards (80 to 90 per cent). It occurs more often in Asian and African-American newborns than Caucasian.

Bile is made by the liver and helps with the digestion of fats. If bile is not removed from the liver, it builds up and begins to damage it. The baby will then develop jaundice, or a yellow colour of the skin as levels of the bile chemical bilirubin rise in the blood. Other symptoms include dark coloured urine and pale stools. Many newborn babies become jaundiced but this is usually temporary. Jaundice lasting for longer than 14 days, especially if there are other symptoms such as an enlarged liver or failure to thrive, is a worrying sign and must be investigated further.

Pathophysiology:
There is no known cause of biliary atresia. There have been many theories about ethiopathogenesis such as Reovirus 3 infection, congenital malformation, congenital CMV infection, autoimmune theory. This means that the etiology and pathogenesis of biliary atresia are largely unknown. However, there have been extensive studies about the pathogenesis and proper management of progressive liver fibrosis, which is arguably one of the most important aspects of biliary atresia patients. As the biliary tract cannot transport bile to the intestine, bile is retained in the liver (known as stasis) and results in cirrhosis of the liver. Proliferation of the small bile ductules occur, and peribiliary fibroblasts become activated. These “reactive” biliary epithelial cells in cholestasis, unlike normal condition, produce and secrete various cytokines such as CCL-2 or MCP-1, Tumor necrosis factor (TNF), Interleukin-6 (IL-6), TGF-beta, Endothelin (ET), and nitric oxide (NO). Among these, TGF-beta is the most important profibrogenic cytokine that can be seen in liver fibrosis in chronic cholestasis. During the chronic activation of biliary epithelium and progressive fibrosis, afflicted patients eventually show signs and symptoms of portal hypertension (esophagogastric varix bleeding, hypersplenism, hepatorenal syndrome(HRS), hepatopulmonary syndrome(HPS)). The latter two syndromes are essentially caused by systemic mediators that maintain the body within the hyperdynamic states. There are three main types of extrahepatic biliary atresia:- Type I: atresia restricted to the common bile duct. Type II: atresia of the common hepatic duct. Type III: atresia of the right and left hepatic duct. Associated anomalies include, in about 20% cases, cardiac lesions, polysplenia, situs inversus, absent vena cava and a preduodenal portal vein.

Symptoms:
Newborns with this condition may appear normal at birth. However, jaundice (a yellow color to the skin and mucous membranes) develops by the second or third week of life. The infant may gain weight normally for the first month, but then will lose weight and become irritable, and have worsening jaundice.

Other symptoms may include:

•Dark urine
•Enlarged spleen
•Floating stools
•Foul-smelling stools
•Pale or clay-colored stools
•Slow growth
•Slow or no weight gain

Diagnosis:
The health care provider will perform a physical exam, which includes feeling the patient’s belly area. The doctor may feel an enlarged liver.

Tests to diagnose biliary atresia include:

•Abdominal x-ray
•Abdominal ultrasound to examine the liver and bile ducts
•A blood test to look for raised levels of bilirubin and check liver enzyme levels and blood clotting
•Hepatobiliary iminodiacetic acid (HIDA) scan, also called cholescintigraphy, to help determine whether the bile ducts and gallbladder are working properly
•Liver biopsy to determine the severity of cirrhosis or to rule out other causes of jaundice
•An abdominal x-ray to look for an enlarged liver and spleen
•X-ray of the bile ducts (cholangiogram)
•An scan to determine how well bile is flowing (HIDA or TEBIDA)

Treatment :
TreatmentIf the intrahepatic biliary tree is unaffected, surgical reconstruction of the extrahepatic biliary tract is possible. This surgery is called a Kasai procedure (after the Japanese surgeon who developed the surgery, Dr. Morio Kasai) or hepatoportoenterostomy.

....

If the atresia is complete, liver transplantation is the only option(currently has a greater than 95 per cent survival rate at one year). Timely Kasai portoenterostomy (e.g. < 60 postnatal days) has shown better outcomes. Nevertheless, a considerable number of the patients, even if Kasai portoenterostomy has been successful, eventually undergo liver transplantation within a couple of years after Kasai portoenterostomy.

Recent large volume studies from Davenport et al. (Ann Surg, 2008) show that age of the patient is not an absolute clinical factor affecting the prognosis. In the latter study, influence of age differs according to the disease etiology—i.e., whether isolated BA, BASM (BA with splenic malformation ), or CBA(cystic biliary atresia).

It is widely accepted that corticosteroid treatment after a Kasai operation, with or without choleretics and antibiotics, has a beneficial effect on the postoperative bile flow and can clear the jaundice; but the dosing and duration of the ideal steroid protocol have been controversial (“blast dose” vs. “high dose” vs. “low dose”). Furthermore, it has been observed in many retrospective longitudinal studies that steroid does not prolong survival of the native liver or transplant-free survival. Davenport at al. also showed (hepatology 2007) that short-term low-dose steroid therapy following a Kasai operation has no effect on the mid- and long-term prognosis of biliary atresia patients.

Prognosis:
Early surgery will improve the survival of more than a third of babies with this condition. The long-term benefit of liver transplant is not yet known, but is expected to improve survival.

Possible Complications:
•Infection
•Irreversible cirrhosis
•Liver failure
•Surgical complications, including failure of the Kasai procedure

Prevention:
The earlier biliary atresia is detected, the less damage it will have done to the liver and the better the chance of a successful outcome to treatment. The current target is to treat babies before they are eight weeks old.

If the liver has not yet been damaged by cirrhosis, the condition is usually treated through an operation called a Kasai portoenterostomy (or a similar procedure). This involves using a loop of bowel to form a duct to drain the bile from the liver. The operation is named after the Japanese surgeon, Professor Morio Kasai, who developed it in 1959. It was first introduced in the UK in the 1960s.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://www.bbc.co.uk/health/physical_health/conditions/biliary_atresia.shtml
http://www.nlm.nih.gov/medlineplus/ency/article/001145.htm
http://en.wikipedia.org/wiki/Biliary_atresia

http://www.mikylah.com/pictures.html

http://www.chw.health.nsw.gov.au/parents/factsheets/biliary_atresia.htm

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Diagnonistic Test

Endoscopic Retrograde Cholangiopancreatography (ERCP)

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Definition:
Endoscopic retrograde cholangiopancreatography  (ERCP) enables the physician to diagnose problems in the liver, gallbladder, bile ducts, and pancreas. The liver is a large organ that, among other things, makes a liquid called bile that helps with digestion. The gallbladder is a small, pear-shaped organ that stores bile until it is needed for digestion. The bile ducts are tubes that carry bile from the liver to the gallbladder and small intestine. These ducts are sometimes called the biliary tree. The pancreas is a large gland that produces chemicals that help with digestion and hormones such as insulin.
click & see the pictures
This procedure uses x-rays and an endoscope to see inside your digestive system and diagnose problems such as tumors, gallstones, and inflammation in your liver, gallbladder, bile ducts, or pancreas. Your doctor might use the test to investigate the cause of jaundice, upper abdominal pain, or unexplained weight loss.

Why an ERCP is Performed
ERCP is most commonly performed to diagnose conditions of the pancreas or bile ducts, and is also used to treat those conditions. It is used to evaluate symptoms suggestive of disease in these organs, or to further clarify abnormal results from blood tests or imaging tests such as ultrasound or CT scan. The most common reasons to do ERCP include abdominal pain, weight loss, jaundice, or an ultrasound or CT scan that shows stones or a mass in these organs.

ERCP may be used before or after gallbladder surgery to assist in the performance of that operation. Bile duct stones can be diagnosed and removed with an ERCP. Tumors, both cancerous and noncancerous, can be diagnosed and then treated with indwelling plastic tubes that are used to bypass a blockage of the bile duct. Complications from gallbladder surgery can also sometimes be diagnosed and treated with ERCP.

In patients with suspected or known pancreatic disease, ERCP will help determine the need for surgery or the best type of surgical procedure to be performed. Occasionally, pancreatic stones can be removed by ERCP.

If the exam shows a gallstone or narrowing of the ducts, the physician can insert instruments into the scope to remove or relieve the obstruction. Also, tissue samples (biopsy) can be taken for further testing.

Preparation
For a week before the test, don’t take aspirin or other NSAIDs because they can irritate the stomach lining and increase your chance of bleeding during the procedure. Also tell the doctor if you are taking blood-thinning medicines or any diabetes medications. People with heart valve problems may also have to take antibiotics before the procedure. Avoid eating or drinking anything for eight hours before the test because it needs to be done on an empty stomach.

Tell your doctor if you are allergic to iodine, which is used for the procedure. Arrange for someone to drive you home because the medication given during the test will make you drowsy.

Your stomach and duodenum must be empty for the procedure to be accurate and safe. You will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours beforehand, depending on the time of your procedure. Also, the physician will need to know whether you have any allergies, especially to iodine, which is in the dye. You must also arrange for someone to take you home—you will not be allowed to drive because of the sedatives. The physician may give you other special instructions.

What can be expected during ERCP
Your throat will be sprayed with a local anesthetic before the test begins to numb your throat and prevent gagging. You will be given medication intravenously to help you relax during the examination. While you are lying in a comfortable position on an X-ray table, an endoscope will be gently passed through your mouth, down your esophagus, and into your stomach and duodenum. The procedure usually lasts about an hour. The endoscope does not interfere with your breathing. Most patients fall asleep during the procedure or find it only slightly uncomfortable. You may feel temporarily bloated during and after the procedure due to the air used to inflate the duodenum. As X-ray contrast material is injected into the pancreatic or bile ducts, you may feel some minor discomfort.

What happens when the test is performed
The test is performed by a specially trained gastroenterologist either in the doctor’s office or in a hospital. You are usually given a sedative through an IV line. You wear a hospital gown for the procedure and lie on your side against a backrest on an x-ray table. If you wear dentures, remove them. A local anesthetic is sprayed into your throat to prevent you from having a gag reflex (choking feeling) when the endoscope is placed inside. The endoscope is about a third of an inch in diameter and 21/2 feet long with a light on the end. It also has holes at the end that allow your doctor to pump air into your intestine, squirt fluid, and suck out liquid or air.

You are asked to swallow at the moment the tube is placed into your throat. This helps guide the endoscope into your esophagus.You are likely to feel pressure against your throat while the tube is in place and you might experience a “full” feeling in your stomach. The doctor or doctor’s assistant gently advances the tube until it reaches your duodenum, the first part of the small intestine.

Next, the doctor inserts a slender tube, called a cannula, through the endoscope, and places the tip of the cannula into the bile duct or the pancreatic duct. These ducts are natural tubes of tissue that drain liquids out of the liver and pancreas. Once the tip of the cannula is lodged inside one of these ducts, the doctor injects contrast dye (usually iodine) through the cannula. The dye can be seen by x-rays, so it lights up the ducts clearly on an x-ray image, showing any obstruction (such as from gallstones or cancer) or unusual widening of the ducts (indicating an obstruction in the past). It also can light up the gallbladder, which connects to the bile duct, and helps the doctor to visualize the liver and pancreatic tissue around the ducts.

Depending on what the x-rays show, the doctor may undertake different interventions using tools operated through the endoscope. The doctor can remove gallstones or take biopsies of suspicious tissue. He or she can prop open narrowed bile ducts with a stent, a tube-shaped object that can be inserted through the scope. Depending on what is done, the test can take from 30 minutes to two hours.

Risk Factors:Complications are rare. One possibility is aspiration-accidentally inhaling saliva into the lungs – which can cause pneumonia. Other risks include inflammation of the pancreas, infection, and bleeding. Injury to the lining of the stomach, esophagus, or intestine, as well as abdominal pain and fever, can also occur.

Possible complications of ERCP include pancreatitis (inflammation of the pancreas), infection, bleeding, and perforation of the duodenum. Except for pancreatitis, such problems are uncommon. You may have tenderness or a lump where the sedative was injected, but that should go away in a few days.

Time required to do the test:
ERCP takes 30 minutes to 2 hours. You may have some discomfort when the physician blows air into the duodenum and injects the dye into the ducts. However, the pain medicine and sedative should keep you from feeling too much discomfort. After the procedure, you will need to stay at the hospital for 1 to 2 hours until the sedative wears off. The physician will make sure you do not have signs of complications before you leave. If any kind of treatment is done during ERCP, such as removing a gallstone, you may need to stay in the hospital overnight.

What happens after the Test is over
You will be monitored in the endoscopy area for 1-2 hours until the effects of the sedatives have worn off. Your throat may be a little sore for a day or two. You will be able to resume your diet and take your routine medication after you leave the endoscopy area, unless otherwise instructed.

Your surgeon will usually inform you of your test results on the day of the procedure. Biopsy results take several days to return, and you should make arrangements with your surgeon to get these results. The effects of sedation may make you forget what you were instructed after the procedure. Call your surgeon’s office for the results.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/endoscopic-retrograde-cholangiopancreatography.shtml
http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/
http://www.alabangmedicalcenter.ph/patientscorner/ERCP.htm

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Diagnonistic Test

Percutaneous Transhepatic Cholangiography (PTCA)

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Definition:

Percutaneous transhepatic cholangiography (PTHC or PTC) is a radiologic technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken. It allows access to the biliary tree in cases where endoscopic retrograde cholangiopancreatography (ERCP) has been unsuccessful. Initially reported in 1937, the procedure became popular after a 1952 report in the English-language literature.

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It is an x-ray test that can help show whether there is a blockage in the liver or the bile ducts that drain it. Since the liver and its drainage system do not normally show up on x-rays, the doctor doing the x-ray needs to inject a special dye directly into the drainage system of the liver. This dye, which is visible on x-rays, should then spread out to fill the whole drainage system. If it does not, that means there is a blockage. This type of blockage might result from a gallstone or a cancer in the liver.

It is predominatly now performed as a therapeutic technique. There are less invasive means of imaging the biliary tree including transabdominal ultrasound, MRCP, computed tomography and endoscopic ultrasound. If the biliary system is obstructed, PTC may be used to drain bile until a more permanent solution for the obstruction is performed (e.g. surgery). Additionally, self expanding metal stents can be placed across malignant biliary strictures to allow palliative drainage. Percutaneous placement of metal stents can be utilised when therapeutic ERCP has been unsuccessful, anatomy is altered precluding endoscopic access to the duodenum, or where there has been separation of the segmental biliary drainage of the liver, allowing more selective placement of metal stents. It is generally accepted that percutanous biliary procedures have higher complication rates than therapeutic ERCP. Complications encountered include infection, bleeding and bile leaks.
Why the test is performed?
Bile is a by-product of protein metabolism. It is created in the liver and excreted into the intestines via the bile ducts. If bile cannot be removed from the body, it collects in the blood and is seen as a yellow discoloration of the skin and eyes (jaundice).

Also, the pancreas creates digestive fluids which drain via a common bile duct into the intestine, and thus obstruction can prevent the drainage of the fluids and may cause pancreatitis (inflammation of the pancreas).

A PTCA test can help identify whether a blockage is causing the jaundice and pancreatitis.

How do you prepare for the test?
Tell your doctor if you have ever had an allergic reaction to lidocaine or the numbing medicine used at the dentist’s office. Also tell your doctor if you could be pregnant. If you have diabetes and take insulin, discuss this with your doctor before the test.

Most people need to have a blood test done some time before the procedure, to make sure they are not at high risk for bleeding complications. If you take aspirin, nonsteroidal anti-inflammatory drugs, or other medicines that affect blood clotting, talk with your doctor. It may be necessary to stop or adjust the dose of these medicines before your test.

You will be told not to eat anything on the morning of the test so that your stomach is empty. This is a safety measure in the unlikely case you have a complication, such as bleeding, that might require repair surgery.

What happens when the test is performed?
You lie on a table wearing a hospital gown. An IV (intravenous) line is inserted into a vein in case you need medicines or fluid during the procedure. An area over your right ribcage is cleaned with an antibacterial soap. Then the radiologist may take a picture of your abdomen with an overhead camera. Medicine is injected through a small needle to numb the skin and the tissue underneath the skin in the area where the dye is to be injected. You may feel some brief stinging from the numbing medicine.

A separate needle is then inserted between two of your ribs on your right side. A small amount of xray dye is injected, and some pictures are taken that are visible on a video screen. Your doctor adjusts the placement of the needle until it is clear that the dye is flowing easily through the ducts (drainage tubes) inside your liver.

Because taking the x-ray pictures sometimes requires a significant amount of time, the doctor replaces the needle with a softer plastic tube. First, the syringe holding the dye is detached from the top of the needle, leaving the needle in place. The doctor then gently pushes a thin wire through the needle and into the duct where the needle has been sitting. Next the needle is pulled out, sliding over the outside end of the wire. The wire is left with one end inside the liver to hold the position where the needle had been. A thin plastic tube similar to an IV line is slid along the wire, like a long bead on a string, until it is in the same place where the needle was. The wire is then pulled out, and the dye syringe is attached to the tube.

More dye is injected through the plastic tube, and pictures are taken with the video camera as the dye spreads inside the liver. If there is no blockage, the dye drains out of the liver through the bile ducts and begins to show up on the x-ray in the area of your small intestine. Once all of the needed pictures have been taken, the plastic tube is pulled out, and a small bandage is placed over your side. The whole test usually takes less than an hour.

Risk Factors:
It is possible to have serious bleeding from this test. In some cases, blood leaks to the outside surface of the liver and causes a buildup of blood there. In other cases, blood can leak directly into the liver’s drainage system, in which case it might start showing up in your intestine, causing a bloody bowel movement. It is less likely that you could develop an infection after the test. The only soreness you are likely to have is at the skin surface where the needle went in. This should last for only a day or two.

In rare cases, the dye used in the test can damage your kidneys. This kidney effect is almost always temporary, but some people have permanent damage.

As with all x-rays, there is a small exposure to radiation. In large amounts, exposure to radiation can cause cancers or (in pregnant women) birth defects. The amount of radiation from the video x-ray in this test is very small-too small to be likely to cause any harm. (The people performing the test on you will wear lead shields, since they would otherwise be exposed to this radiation over and over, which could be more of a danger.)

Must you do anything special after the test is over?
Call your doctor right away if you have pain in your right abdomen or shoulder, fever, dizziness, or a change in your stool color to black or red.

How long is it before the result of the test is known?
You may be told a few early results of your test as soon as the test is done. It takes a day or two for the radiologist to review the x-rays more thoroughly and to give your doctor a full report.

RESULTS:-

Normal Result:-The bile ducts are normal in size and appearance for the age of the patient.

Abnormal Results:-The results may show that the ducts are enlarged, which may indicate the ducts are blocked. The blockage may be caused by infection, scarring, or stones. It may also indicate cancer in the bile ducts, liver, pancreas, or region of the gallbladder.

You may click & See:–
*Blocked bile ducts
*Cholangitis (infection in common bile duct)
Special considerations:-
A PTCA may be done if an endoscopic retrograde cholangiopancreatography ( ERCP) cannot be performed or has failed in the past.

An MRCP (magnetic resonance cholangiopancreatography) is a newer, non-invasive imaging method, based on MRI, which provides similar views of the bile ducts.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/percutaneous-transhepatic-cholangiography.shtml
http://en.wikipedia.org/wiki/Percutaneous_transhepatic_cholangiography
http://www.healthline.com/adamcontent/percutaneous-transhepatic-cholangiogram

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Ailmemts & Remedies

Cholangiocarcinoma

Alternative Names: Bile duct cancer

Definition: Cholangiocarcinoma is a cancerous (malignant) growth in the bile duct which drain bile from the liver into the small intestine. Other biliary tract cancers include pancreatic cancer, gall bladder cancer, and cancer of the ampulla of Vater. Cholangiocarcinoma is a relatively rare adenocarcinoma, with an annual incidence of 1–2 cases per 100,000 in the Western world, but rates of cholangiocarcinoma have been rising worldwide over the past several decades.

CLICK  & SEE THE PICTURES

Causes
Cancerous tumors of the bile ducts are usually slow-growing and do not spread (metastasize) quickly. However, many of these tumors are already advanced by the time they are found.

A cholangiocarcinoma may start anywhere along the bile ducts. These tumors block off the bile ducts.

They affect both men and women. Most patients are older than 65.

Risk Factors:
Although most patients present without any known risk factors evident, a number of risk factors for the development of cholangiocarcinoma have been described; in the Western world, the most common of these is primary sclerosing cholangitis (PSC), an inflammatory disease of the bile ducts which is in turn closely associated with ulcerative colitis (UC). Epidemiologic studies have suggested that the lifetime risk of developing cholangiocarcinoma for a person with PSC is 10%–15%,  although autopsy series have found rates as high as 30% in this population. The mechanism by which PSC increases the risk of cholangiocarcinoma is not well-understood.
Certain parasitic liver diseases may be risk factors as well. Colonization with the liver flukes Opisthorchis viverrini (found in Thailand, Laos, and Malaysia) or Clonorchis sinensis (found in Japan, Korea, and Vietnam) has been associated with the development of cholangiocarcinoma. Patients with chronic liver disease, whether in the form of viral hepatitis (e.g. hepatitis B or C), alcoholic liver disease, or cirrhosis from other causes, are at increased risk of cholangiocarcinoma. HIV infection was also identified in one study as a potential risk factor for cholangiocarcinoma, although it was unclear whether HIV itself or correlated factors (e.g. hepatitis C infection) were responsible for the association.

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Congenital liver abnormalities, such as Caroli’s syndrome or choledochal cysts, have been associated with an approximately 15% lifetime risk of developing cholangiocarcinoma. The rare inherited disorders Lynch syndrome II and biliary papillomatosis are associated with cholangiocarcinoma. The presence of gallstones (cholelithiasis) is not clearly associated with cholangiocarcinoma. However, intrahepatic stones (so-called hepatolithiasis), which are rare in the West but common in parts of Asia, have been strongly associated with cholangiocarcinoma. Exposure to Thorotrast, a form of thorium dioxide which was used as a radiologic contrast medium, has been linked to the development of cholangiocarcinoma as late as 30–40 years after exposure; Thorotrast was banned in the United States in the 1950s due to its carcinogenicity.

Ricks for this condition include:

* Bile duct (choledochal) cysts
* Chronic biliary irritation
* History of infection with the parasitic worm, liver flukes
* Primary sclerosing cholangitis

Cholangiocarcinoma is rare. It occurs in approximately 2 out of 100,000 people.

Symptoms
* Chills
* Clay-colored stools
* Fever
* Itching
* Loss of appetite
* Pain in the upper right abdomen that may radiate to the back
* Weight loss
* Yellowing of the skin (jaundice)

The most common physical indications of cholangiocarcinoma are abnormal liver function tests, jaundice (yellowing of the eyes and skin), which occurs only when bile ducts are blocked by the tumor, abdominal pain (30%–50%), generalized itching (66%), weight loss (30%–50%), fever (up to 20%), or changes in stool or urine color.To some extent, the symptoms depend upon the location of the tumor: Patients with cholangiocarcinoma in the extrahepatic bile ducts (outside the liver) are more likely to have jaundice, while those with tumors of the bile ducts within the liver often have pain without jaundice.
.Yellowing of the skin and eyes (jaundice)->     CLICK & SEE
Blood tests of liver function in patients with cholangiocarcinoma often reveal a so-called “obstructive picture,” with elevated bilirubin, alkaline phosphatase, and gamma glutamyl transferase levels, and relatively normal transaminase levels. Such laboratory findings suggest obstruction of the bile ducts, rather than inflammation or infection of the liver, as the primary cause of the jaundice.  CA19-9 is elevated in most cases

Diagnosis:–
Cholangiocarcinoma is definitively diagnosed from tissue, i.e. it is proven by biopsy or examination of the tissue excised at surgery. It may be suspected in a patient with obstructive jaundice. Considering it as the working-diagnosis may be challenging in patients with primary sclerosing cholangitis (PSC); such patients are at high risk of developing cholangiocarcinoma, but the symptoms may be difficult to distinguish from those of PSC. Furthermore, in patients with PSC, such diagnostic clues as a visible mass on imaging or biliary ductal dilatation may not be evident.

Exams and Tests:-
Blood tests
Blood tests that show abnormal function.
There are no specific blood tests that can diagnose cholangiocarcinoma by themselves. Serum levels of carcinoembryonic antigen (CEA) and CA19-9 are often elevated, but are not sensitive or specific enough to be used as a general screening tool. However, they may be useful in conjunction with imaging methods in supporting a suspected diagnosis of cholangiocarcinoma.
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Abdominal imaging
CT scan showing cholangiocarcinomaUltrasound of the liver and biliary tree is often used as the initial imaging modality in patients with suspected obstructive jaundice. Ultrasound can identify obstruction and ductal dilatation and, in some cases, may be sufficient to diagnose cholangiocarcinoma.  Computed tomography (CT) scanning may also play an important role in the diagnosis of cholangiocarcinoma.

Tests that show a tumor or blockage in the bile duct:
*Abdominal CT scan
*Abdominal ultrasound
*CT scan-directed biopsy
*Cytology
*Endoscopic retrograde cholangiopancreatography (ERCP)
*Percutaneous transhepatic cholangiogram (PTCA)

Liver function tests (especially bilirubin)

Treatment  :-
The goal is to treat the cancer and the blockage it causes. When possible, surgery to remove the tumor is the treatment of choice and may result in a cure. However, often the cancer has already spread by the time it is diagnosed.

Chemotherapy or radiation may be given after surgery to decrease the risk of the cancer returning. However, the benefit of this treatment is not certain.

Endoscopic therapy or surgery can clear blockages in the biliary ducts and relieve jaundice in patients when the tumor cannot be removed.

For patients with cancer that cannot be removed, radiation therapy may be beneficial. Chemotherapy may be added to radiation therapy or used when the tumor has spread. However, this is rarely effective.

Support Groups:-
You can ease the stress of illness by joining a support group with members who share common experiences and problems (see cancer – support group).

Hospice is often a good resource for patients with cholangiocarcinoma that cannot be cured.

Prognosis:
Surgical resection offers the only potential chance of cure in cholangiocarcinoma. For non-resectable cases, the 5-year survival rate is 0% where the disease is inoperable because distal lymph nodes show metastases[63], and less than 5% in general. Overall median duration of survival is less than 6 months in inoperable, untreated, otherwise healthy patients with tumors involving the liver by way of the intrahepatic bile ducts and hepatic portal vein.

For surgical cases, the odds of cure vary depending on the tumor location and whether the tumor can be completely, or only partially, removed. Distal cholangiocarcinomas (those arising from the common bile duct) are generally treated surgically with a Whipple procedure; long-term survival rates range from 15%–25%, although one series reported a five year survival of 54% for patients with no involvement of the lymph nodes. Intrahepatic cholangiocarcinomas (those arising from the bile ducts within the liver) are usually treated with partial hepatectomy. Various series have reported survival estimates after surgery ranging from 22%–66%; the outcome may depend on involvement of lymph nodes and completeness of the surgery. Perihilar cholangiocarcinomas (those occurring near where the bile ducts exit the liver) are least likely to be operable. When surgery is possible, they are generally treated with an aggressive approach often including removal of the gallbladder and potentially part of the liver. In patients with operable perihilar tumors, reported 5-year survival rates range from 20%–50%.

The prognosis may be worse for patients with primary sclerosing cholangitis who develop cholangiocarcinoma, likely because the cancer is not detected until it is advanced. Some evidence suggests that outcomes may be improving with more aggressive surgical approaches and adjuvant therapy.

Possible Complications :-
*Infection
*Liver failure
*Spread (metastasis) of tumor to other organs.

When to Contact a Medical Professional :-
Call your health care provider if you have jaundice or other symptoms of cholangiocarcinoma.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Cholangiocarcinoma
http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/000291.htm

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