Diagnostic accuracy of magnetic resonance and endoscopic retrograde cholangiography in primary sclerosing cholangitis

Diagnosis of sclerosing cholangitis in children: blinded, comparative study of magnetic resonance versus endoscopic cholangiography

BACKGROUND

Magnetic resonance cholangiography (MRC) has been validated as comparable to endoscopic retrograde cholangiography (ERC) for the diagnosis of sclerosing cholangitis (SC) in adult patients. In children, MRC is widely used based mainly on non-comparative studies.

PATIENTS AND METHODS

ERCs and MRCs of seven children (median age 9, range: 7-20 years) with SC and 17 controls (median age 6, range: 2 months-20 years) with other chronic liver diseases were reviewed in a blinded, random and independent way. All patients underwent both examinations within a 6-months slot. All ERCs and 17 MRCs were performed under general anesthesia. One radiologist evaluated both ERCs and MRCs and one interventional endoscopist independently reviewed only ERCs. Reviewers did not receive any clinical information. Diagnosis of SC, established on the basis of history, laboratory data, radiological examinations and clinical course, was used as gold standard to compare ERC and MRC diagnostic accuracy.

RESULTS

Overall image quality was graded as very good in 57% of MRC and in 71% of ERC cases; difference was not statistically significant (P=0.24) although the probability for MRC to be diagnostic increased with patient's age. Depiction of first, second and fourth-order intrahepatic bile duct was better in ERC (P=0.004, 0.02 and 0.023, respectively); depiction of the extrahepatic bile duct was comparable (P=0.052). Diagnostic accuracy of MRC and ERC was very high, without statistically significant difference (P=0.61).

CONCLUSION

Despite an overall better depiction of the biliary tree by ERC, MRC is comparable for the diagnosis of SC in children. These data support MRC as the first imaging approach in children with suspected SC.

Dynamic gadoxetate-enhanced MRI for the assessment of total and segmental liver function and volume in primary sclerosing cholangitis

PURPOSE

To evaluate dynamic hepatocyte-specific contrast-enhanced MRI (DHCE-MRI) for the assessment of global and segmental liver volume and function in patients with primary sclerosing cholangitis (PSC), and to explore the heterogeneous distribution of liver function in this patient group.

MATERIALS AND METHODS

Twelve patients with primary sclerosing cholangitis (PSC) and 20 healthy volunteers were examined using DHCE-MRI with Gd-EOB-DTPA. Segmental and total liver volume were calculated, and functional parameters (hepatic extraction fraction [HEF], input relative blood-flow [irBF], and mean transit time [MTT]) were calculated in each liver voxel using deconvolutional analysis. In each study subject, and incongruence score (IS) was constructed to describe the mismatch between segmental function and volume. Among patients, the liver function parameters were correlated to bile duct obstruction and to established scoring models for liver disease.

RESULTS

Liver function was significantly more heterogeneously distributed in the patient group (IS 1.0 versus 0.4). There were significant correlations between biliary obstruction and segmental functional parameters (HEF rho -0.24; irBF rho -0.45), and the Mayo risk score correlated significantly with the total liver extraction capacity of Gd-EOB-DTPA (rho -0.85).

CONCLUSION

The study demonstrates a new method to quantify total and segmental liver function using DHCE-MRI in patients with PSC.

Primary sclerosing cholangitis: diagnosis, prognosis, and management

Primary sclerosing cholangitis (PSC) is a chronic immune-mediated disease of the liver of unclear etiology, characterized by chronic inflammation and fibrosis of bile ducts. It primarily affects middle-aged men and is associated with 4-fold increased mortality as compared with an age- and sex-matched population. Progressive biliary and hepatic damage results in portal hypertension and hepatic failure in a significant majority of patients over a 10- to 15-year period from the initial diagnosis. In addition, PSC confers a markedly increased risk of hepatobiliary cancer, including cholangiocarcinoma and gallbladder cancer, as compared with the general population, and cancer is the leading cause of mortality in patients with PSC. It is associated with inflammatory bowel disease in 70% of patients and increases the risk of colorectal cancer almost 10-fold. Despite significant research efforts in this field, the pathogenic mechanisms of PSC are still incompletely understood, although growing evidence supports the role of genetic and immunologic factors. There are no proven medical therapies that alter the natural course of the disease. Thus, liver transplantation is the only available treatment for patients with advanced PSC, with excellent outcomes in this population.

Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines

The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

Biliary stent therapy for dominant strictures in patients affected by primary sclerosing cholangitis

The diagnosis and the treatment of dominant strictures (DS) in patients with primary sclerosing cholangitis (PSC) is challenging and the scientific literature on the subject is quite limited. Only level II and level III evidence is available to guide physicians managing patients with DS and PSC. For the diagnosis, intraductal endoscopic ultrasound is the most sensitive (64%) and specific (95%) test. However, the majority of cases require a combination of several different diagnostic tests, as there is no single investigation that can rule out malignancy in this group of patients. For the treatment, serial endoscopic or percutaneous dilatations provide 1- and 3-year biliary duct patency in 80 and 60% of patients, respectively. Dilatation and stenting are the most common interventions, although the optimal duration of treatment has still not been clearly defined. Bile duct resection and/or bilioenteric bypass are currently indicated only for patients with preserved liver function. For all other patients, benign DS can be treated with endoscopic dilatation with short-term stenting. This approach is effective and safe and does not increase the risk of malignant transformation or complications for liver transplant candidates. During the last decade, the use of self-expandable metallic stents for benign diseases has become an innovative option. The aim of this article is to review the diagnostic and therapeutic strategies for patients affected by PSC and DS with specific emphasis on the outcomes of patients treated with temporary stents.

Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic, progressive, cholestatic liver disease characterized by multifocal strictures of intra and extrahepatic bile ducts. PSC occurs more commonly in men and is often associated with inflammatory bowel disease. At present, there is no effective medical therapy for PSC. Current management of patients with PSC is centered on endoscopic therapy of biliary strictures, management of complications of chronic cholestasis and of progressive liver disease, and close clinical monitoring for development of cholangiocarcinoma, as well as for timely referral for liver transplantation.

Inflammatory bowel disease in primary sclerosing cholangitis: a robust yet changing relationship

BACKGROUND

Primary sclerosing cholangitis (PSC) has a well-established association with inflammatory bowel disease (IBD) and may represent a distinctive phenotype. It is unknown whether changes in the clinical and endoscopic presentation of newly diagnosed IBD among patients with PSC might have occurred over time.

METHODS

Initial clinical and endoscopic presentations of IBD in PSC were studied for 2 different time periods: 1993 to 1997 (early cohort) compared with 2003 to 2007 (recent cohort).

RESULTS

The baseline characteristics were similar in the 57 early cohort and 72 recent cohort patients. Compared with the recent cohort, alkaline phosphatase concentrations were higher in the early cohort (7.1 versus 2.6 × upper limit of normal, P = 0.0001). PSC was diagnosed before IBD in the recent cohort compared with the early cohort (50% versus 35%, P = 0.0009). The initial clinical and endoscopic presentations of IBD were similar in the 2 cohorts. The majority of patients had mild pancolitis, whereas rectal sparing and backwash ileitis were detected in one third and one fourth of patients, respectively. In addition, no differences in IBD outcomes or PSC characteristics were revealed. Immunomodulators and biological treatments were more commonly used in the recent cohort when compared with the early cohort (90% versus 56%, P = 0.03, and 13% versus 4%, P = 0.08, respectively).

CONCLUSIONS

IBD in PSC has unique characteristics, and the clinical features of this unique presentation have remained stable over time. A shift in the timing of diagnosis of the 2 diseases has occurred in recent years, with PSC being more often diagnosed first.

Investigative MRI cholangiopancreatography for primary sclerosing cholangitis-type lesions in children with IBD

OBJECTIVES

The aim of the study was to estimate the frequency of primary sclerosing cholangitis (PSC)-type lesions in children with inflammatory bowel disease (IBD) by means of magnetic resonance cholangiopancreatography (MRCP), and to investigate the association between a series of easily applicable data on the one hand and the presentation of such lesions at MRCP on the other hand.

METHODS

Collected demographic, laboratory, and magnetic resonance enterography data from the records of 73 children with IBD were cross-sectionally related to the MRCP-based diagnosis.

RESULTS

Around the time of MRCP, the distribution of IBD subtypes was 64.4%, 24.7%, and 11% for Crohn disease, indeterminate colitis, and ulcerative colitis, respectively. A total of 11 patients (15.1%) were identified with PSC-type lesions. Demographic and magnetic resonance enterography data were unrelated to the MRCP outcome. Biochemical abnormalities were of low prevalence (<50%) among patients with PSC. The abnormality prevalences of aspartate transaminase, alanine transaminase, and γ-glutamyl transferase were significantly higher in the PSC group, both at initial diagnosis of IBD and at the time of MRCP. Less-consistent results were documented for bilirubin and alkaline phosphatase, especially at initial diagnosis of IBD.

CONCLUSIONS

The abnormality prevalences of aspartate transaminase, alanine transaminase, and γ-glutamyl transferase were significantly higher in the PSC group. Nevertheless, PSC-type lesions frequently occur in pediatric IBD, even if the biochemical profile is hardly indicative of this probability.

Klatskin-like lesions

Hilar cholangiocarcinoma, also known as Klatskin tumour, is the commonest type of cholangiocarcinoma. It poses unique problems in the diagnosis and management because of its anatomical location. Curative surgery in the form of major hepatic resection entails significant morbidity. About 5-15% of specimens resected for presumed Klatskin tumour prove not to be cholangiocarcinomas. There are a number of inflammatory, infective, vascular, and other pathologies, which have overlapping clinical and radiological features with a Klatskin tumour, leading to misinterpretation. This paper aims to summarise the features of such Klatskin-like lesions that have been reported in surgical literature.

Targeted MRI contrast agents for pediatric hepatobiliary disease

New options are available for the magnetic resonance imaging (MRI) assessment of pediatric hepatobiliary disease. This article describes the potential utility for MRI with contrast agents tailored for hepatobiliary imaging. MRI contrast agents that preferentially target the liver may be helpful in characterizing liver masses and bile duct abnormalities in select children. The imaging approach is noninvasive and relatively rapid to perform. It also provides anatomic and functional information and is a radiation-free alternative to other imaging strategies. This relatively new imaging procedure is placed in the context of more established imaging modalities. The pharmacokinetics, technical considerations, and potential applications of these hepatobiliary-specific contrast agents also are discussed.

Liver disorders in inflammatory bowel disease

Disorders of the hepatobiliary system are relatively common extraintestinal manifestations of inflammatory bowel disease (IBD). These disorders are sometimes due to a shared pathogenesis with IBD as seen in primary sclerosing cholangitis (PSC) and small-duct primary sclerosing cholangitis (small-duct PSC). There are also hepatobiliary manifestations such as cholelithiasis and portal vein thrombosis that occur due to the effects of chronic inflammation and the severity of bowel disease. Lastly, medications used in IBD such as sulfasalazine, thiopurines, and methotrexate can adversely affect the liver. It is important to be cognizant of these disorders as some do have serious long-term consequences. The management of these disorders often requires the expertise of multidisciplinary teams to achieve the best outcomes.

Hepatopancreatobiliary manifestations of inflammatory bowel disease

Inflammatory bowel disease (IBD) is frequently associated with extraintestinal manifestations such as hepatopancreatobiliary manifestations (HPBMs), which include primary sclerosing cholangitis (PSC), pancreatitis, and cholelithiasis. PSC is correlated with IBD, particularly ulcerative colitis (UC); 70-80% of PSC patients in Western countries and 20-30% in Japan have comorbid UC. Therefore, patients diagnosed with PSC should be screened for UC by total colonoscopy. While symptoms of PSC-associated UC are usually milder than PSC-negative UC, these patients have a higher risk of colorectal cancer, particularly in the proximal colon. Therefore, regular colonoscopy surveillance is required regardless of UC symptoms. Administration of 5-aminosalicylic acid or ursodeoxycholic acid may prevent colorectal cancer and cholangiocarcinoma. While PSC is diagnosed by diffuse multifocal strictures on cholangiography, it must be carefully differentiated from immunoglobulin G4 (IgG4)-associated cholangitis, which shows a similar cholangiogram but requires different treatment. When PSC is suspected despite a normal cholangiogram, the patient may have small-duct PSC, which requires a liver biopsy. IBD patients have a high incidence of acute and chronic pancreatitis. Most cases are induced by cholelithiasis or medication, although some patients may have autoimmune pancreatitis (AIP), most commonly type 2 without elevation of serum IgG4. AIP should be accurately identified based on characteristic image findings, because AIP responds well to corticosteroids. Crohn's disease is frequently associated with gallstones, and several risk factors are indicated. HPBMs may influence the management of IBD, therefore, accurate diagnosis and an appropriate therapeutic strategy are important, as treatment depends upon the type of HPBM.

Hepatobiliary complications of inflammatory bowel disease

Several hepatobiliary abnormalities have been described in association with inflammatory bowel disease (IBD), including primary sclerosing cholangitis (PSC), small duct PSC, chronic hepatitis, cryptogenic cirrhosis, cholangiocarcinoma, and cholelithiasis. PSC is the most common biliary condition in patients with IBD, with an incidence ranging from 2.5% to 7.5%. PSC usually progresses insidiously and eventually leads to cirrhosis independent of inflammatory bowel disease activity. There is a very high incidence of cholangiocarcinoma and an elevated risk for developing colon cancer in patients with PSC. Medical therapy has not proven successful in slowing disease progression or prolonging survival. Treatment of symptoms due to cholestasis, such as pruritis and steatorrhea, is an important aspect of the medical care of patients with PSC. Our preferred treatment of pruritis due to cholestasis is with bile acid binding exchange resins, such as cholestyramine or colestipol. Endoscopic manipulation is recommended for treating complications of recurrent cholangitis or worsening jaundice in the setting of a dominant stricture, but endoscopic approaches have not been conclusively demonstrated to improve survival or decrease the need for liver transplantation. Liver transplantation remains the only effective treatment of advanced PSC, and should be considered in patients with complications of cirrhosis or intractable pruritis or fatigue.

Analytical review of diagnosis and treatment strategies for dominant bile duct strictures in patients with primary sclerosing cholangitis

BACKGROUND

The diagnosis and treatment of indeterminate dominant strictures (DS) in patients with primary sclerosing cholangitis (PSC) is challenging and the literature on the subject is scarce.

OBJECTIVES

This review aims to appraise and synthesize the evidence published in the English-language medical literature on this topic.

METHODS

Scientific papers published from 1950 until week 4 of July 2010 were extracted from MEDLINE, Ovid Medline In-Process, the Cochrane Database of Systematic Reviews, the Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, EMBASE, PubMed and the National Library of Medicine Gateway.

RESULTS

Strategies for the optimal management of DS in PSC patients are supported only by level II and III evidence. Intraductal endoscopic ultrasound appears to be the most sensitive (64%) and specific (95%) diagnostic test for the evaluation of DS in PSC. Endoscopic and percutaneous dilatations achieve 1- and 3-year palliation in 80% and 60% of patients, respectively. Although dilatation and stenting are the most common palliative interventions in DS, no randomized trials on the optimal duration of treatment have been conducted.

CONCLUSIONS

In benign DS, endoscopic dilatation with short-term stenting seems to be effective and safe and does not increase the risks for malignant transformation or complications after liver transplantation. Surgical bile duct resection and/or bilioenteric bypass are indicated only in patients with preserved liver function.

[Primary sclerosing cholangitis: diagnosis, prognosis and treatment]

Primary sclerosing cholangitis is a chronic cholestatic disease characterized by inflammation with fibrosis and obliteration of the intra- and extrahepatic bile ducts. This disease is usually associated with ulcerative colitis. The process of chronic cholestasis eventually leads to biliary cirrhosis. The prevalence of primary sclerosing cholangitis is low in southern Europe but is especially high in Scandinavian countries. The etiopathogenesis is unknown but immune disorders, potential toxic agents or intestinal infections, ischemic injury to the bile ducts, and possibly alterations in hepatobiliary transporters are known to play a role. The disease manifests at the age of approximately 40 years, mainly in men with clinical and laboratory features of cholestasis but may also be asymptomatic. There are specific forms in which the small intrahepatic bile ducts are involved, mainly affecting children, as well as overlap syndromes with autoimmune hepatitis. A form characterized by an increase in IgG4 has been described, which is usually associated with autoimmune pancreatitis. The key diagnostic procedure is endoscopic retrograde cholangiography, although magnetic resonance cholangiography is the first diagnostic procedure that should be used since it is equally informative and non-invasive. Liver biopsy is not essential for diagnosis. Primary sclerosing cholangitis is a progressive disease with a probability of transplant-free survival of 18 years in asymptomatic forms and of 8.5 years in symptomatic forms. Cholangiocarcinoma can result from the disease and confers a poor prognosis. There is no specific treatment although ursodeoxycholic acid improves the biochemical alterations of cholestasis. Liver transplantation is the last therapeutic resort with good results in terms of survival although the disease can recur in the transplanted liver.

A national audit of temporal trends in endoscopic retrograde cholangiopancreatography in Norway

OBJECTIVE

The introduction of non-invasive imaging for biliary-pancreatic diseases has changed the indications and volumes of endoscopic retrograde cholangiopancreatography (ERCP) over time. This study aimed to provide national figures on ERCP in Norway over the last decade.

MATERIAL AND METHODS

Data from four national surveys on ERCP activity collected from 1998 to 2009 at the surgical and medical departments of all Norwegian hospitals were analyzed for variations in volumes among centers, regions, and specialties over time.

RESULTS

A total of 42,260 procedures were reported (average 3842 procedures per year, range 3492-4632). The number of hospitals with ERCP decreased from 41 to 35 and the annual number of procedures decreased by 13% (from 4632 to 4036), but the number of ERCP endoscopists remained stable at ~100. The proportion of procedures performed by surgeons decreased from 40% to 32% (p < 0.001) during the first half of the study period; the number of gastrointestinal surgeons performing ERCP remained stable in the latter half (46% and 48% for 2004 and 2008, respectively). In 2004, 15 endoscopists signed up for a formal ERCP training program, including 8 (53%) surgeons. This number increased to 21 (48%) in 2008. A non-significant decrease in referrals (49% in 2002 vs. 35% in 2005) between various ERCP centers was reported. Regional variation in ERCP volumes leveled off during the study period.

CONCLUSIONS

Though the number of both procedures and hospitals performing ERCP in Norway decreased, the proportion of low-volume and high-volume centers remained steady. The proportion of procedures by gastroenterological surgeons decreased significantly, yet roughly half of the endoscopists in ERCP training programs are surgeons. Regional variation in the ERCP numbers appears to have diminished.

Primary sclerosing cholangitis: meta-analysis of diagnostic performance of MR cholangiopancreatography

PURPOSE

To determine the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) for detection of primary sclerosing cholangitis (PSC) in patients with biochemical cholestasis.

MATERIALS AND METHODS

Two reviewers searched MEDLINE, EMBASE, and other electronic databases to identify prospective studies in which MRCP was evaluated and compared with endoscopic retrograde cholangiopancreatography (ERCP), clinical examination, and/or histologic analysis for diagnosis of PSC in cholestasis and control cases. Main study inclusion criteria were (a) use of ERCP or percutaneous transhepatic cholangiography (PTC) as part of the reference standard for the diagnosis of PSC, (b) inclusion of patients with hepatobiliary disease other than PSC (ie, nonhealthy control subjects), (c) blinding of MRCP image readers to reference-standard results, (d) prospective study with ERCP or MRCP performed after subject recruitment into the study, and (e) inclusion of raw data (for true-positive, false-positive, true-negative, and false-negative results) that could be found or calculated from the original study data. Major exclusion criteria were duplicate article (on a primary study) that contained all or some of the original study data and inclusion of fewer than 10 patients with PSC. Methodologic quality was assessed by using the Quality Assessment of Diagnostic Accuracy Studies tool. Bivariate random-effects meta-analytic methods were used to estimate summary, sensitivity, specificity, and receiver operating characteristic (ROC) curves.

RESULTS

Six manuscripts with 456 subjects (with 623 independent readings)--185 with PSC--met the study inclusion criteria. The summary area under the ROC curve was 0.91. High heterogeneity (inconsistency index, 78%) was found but became moderate (inconsistency index, 36%) with the exclusion of one study in which the diagnostic threshold was set for high sensitivity. There was no evidence of publication bias (P = .27, bias coefficient analysis). Sensitivity and specificity of MRCP for PSC detection across all studies were 0.86 and 0.94, respectively. Positive and negative likelihood ratios with MRCP were 15.3 and 0.15, respectively. In patients with high pretest probabilities, MRCP enabled confirmation of PSC; in patients with low pretest probabilities, MRCP enabled exclusion of PSC. Worst-case-scenario (pretest probability, 50%) posttest probabilities were 94% and 13% for positive and negative MRCP results, respectively.

CONCLUSION

MRCP has high sensitivity and very high specificity for diagnosis of PSC. In many cases of suspected PSC, MRCP is sufficient for diagnosis, and, thus, the risks associated with ERCP can be avoided.

Hepatopancreatobiliary manifestations and complications associated with inflammatory bowel disease

Diseases involving the hepatopancreatobiliary (HPB) system are frequently encountered in patients with inflammatory bowel disease (IBD). Hepatobiliary manifestations constitute some of the most common extraintestinal manifestations of IBD. They appear to occur with similar frequency in patients with Crohn's disease or ulcerative colitis. HPB manifestations may occur in following settings: 1) disease possibly associated with a shared pathogenetic mechanism with IBD including primary sclerosing cholangitis (PSC), small-duct PSC/pericholangitis and PSC/autoimmune hepatitis overlap, acute and chronic pancreatitis related to IBD; 2) diseases which parallel structural and physiological changes seen with IBD, including cholelithiasis, portal vein thrombosis, and hepatic abscess; and 3) diseases related to adverse effects associated with treatment of IBD, including drug-induced hepatitis, pancreatitis (purine-based agents), or liver cirrhosis (methotrexate), and reactivation of hepatitis B, and biologic agent-associated hepatosplenic lymphoma. Less common HPB manifestations that have been described in association with IBD include autoimmune pancreatitis (AIP), IgG4-associated cholangitis (IAC), primary biliary cirrhosis (PBC), fatty liver, granulomatous hepatitis, and amyloidosis. PSC is the most significant hepatobiliary manifestation associated with IBD and poses substantial challenges in management requiring a multidisciplinary approach. The natural disease course of PSC may progress to cirrhosis and ultimately require liver transplantation in spite of total proctocolectomy with ileal-pouch anal anastomosis. The association between AIP, IAC, and elevated serum IgG4 in patients with PSC is intriguing. The recently reported association between IAC and IBD may open the door to investigate these complex disorders. Further studies are warranted to help understand the pathogenesis of HPB manifestations associated with IBD, which would help clinicians better manage these patients. An interdisciplinary approach, involving gastroenterologists, hepatologists, and, in advanced cases, general, colorectal, and transplant surgeons is advocated.

Approach to biliary imaging amongst consultant and specialist registrars in gastroenterology in a national setting

BACKGROUND

Radiological investigation plays an important role in the management of conditions affecting the hepatobiliary system. However, multiple imaging modalities exist and inappropriate requesting can lead to delays in diagnosis and subsequent treatment.

AIMS

To assess the approach to biliary imaging amongst Irish gastroenterologists across a number of scenarios, and examine and seek to explain any variations.

METHODS

A survey to determine "best practice" radiological investigation of real-life clinical scenarios was designed and distributed to fully trained and trainee gastroenterologists nationally.

RESULTS

The responses to scenarios ranged from near unanimity, with up to 97% agreement, to notable lack of consensus amongst both registrars and consultants.

CONCLUSION

An algorithm for the management of hepatobiliary disease was formulated.

Unique features of primary sclerosing cholangitis in children

PURPOSE OF REVIEW

To summarize publications on juvenile primary sclerosing cholangitis (PSC) published over the past 5 years. These studies contribute to the understanding of the clinical features, diagnostic pathways, genetic aspects, treatment and outcome of this condition.

RECENT FINDINGS

Sclerosing cholangitis with strong autoimmune features is particularly frequent in paediatric age, where it is more common in girls, responds to immunosuppressive treatment and has a better prognosis than classical PSC. Modern-day magnetic resonance cholangiography allows accurate diagnosis of bile duct disease in most cases. Prolonged oral vancomycin treatment may be beneficial in difficult-to-treat PSC associated with inflammatory bowel disease. Juvenile PSC has a high recurrence rate after liver transplantation. PSC susceptibility and resistance are associated with both human leucocyte antigen-related and unrelated genetic factors.

SUMMARY

Studies on large cohorts of children with PSC are needed for a better understanding of pathogenic mechanisms, response to treatment and outcome of this serious condition.

Endoscopic retrograde cholangiopancreatography in diagnosis and treatment of primary sclerosing cholangitis

Primary sclerosing cholangitis is characterized by progressive fibrosing obliteration of the biliary tract. In some cases the disease is restricted to the small bile ducts, but most patients develop fibrotic stenoses of the larger bile ducts. Despite advances in magnetic resonance cholangiography, in unclear cases endoscopic retrograde cholangiography is necessary to make the correct diagnosis. In patients with total or subtotal strictures of the large bile ducts, these so-called dominant stenoses may be treated by endoscopic balloon dilatation and/or stent placement, though in the large majority of cases a stent placement is not necessary. Several studies showed an improvement of biochemical parameters after endoscopic treatment, and actuarial survival in these patients was improved compared with predicted survival. Endoscopic retrograde cholangiography allows tissue sampling, brush cytology, and bile analysis for early detection of cholangiocarcinoma, a major complication of primary sclerosing cholangitis. Despite successful endoscopic opening of bile duct stenoses, patients often progress to liver failure, leading to liver transplantation as the treatment of choice.

Endoscopic dilation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment

BACKGROUND

Primary sclerosing cholangitis is characterized by progressive fibrotic inflammation and obliteration of intra- and/or extrahepatic bile ducts. Total or subtotal stenoses of major bile ducts are associated with reduced survival.

OBJECTIVE

To evaluate the outcome after long-term endoscopic treatment.

DESIGN

Prospective, single-center study.

SETTING

Tertiary care academic medical center.

PATIENTS

A total of 171 patients treated with ursodeoxycholic acid were followed for as long as 20 years. At entry, 20 patients had dominant stenoses, and during a median follow-up period of 7.1 years, dominant stenosis developed in another 77.

INTERVENTIONS

Ninety-six patients with dominant stenoses were treated by repeated balloon dilation; 5 patients with complete obstruction with bacterial cholangitis were stented.

MAIN OUTCOME MEASUREMENTS

Survival free of liver transplantation, number of procedures, complications.

RESULTS

In total, 500 balloon dilations were performed and 5 stents were placed. Complications were pancreatitis (2.2%), bacterial cholangitis (1.4%), and bile duct perforation (0.2%); there were no deaths. Repeated endoscopic interventions allowed the preservation of a functioning common bile duct and of at least 1 hepatic duct up to 2 cm above the bifurcation in all patients. Progression of intrahepatic bile duct and liver disease led to the need for liver transplantation in 22 of 96 patients. Five years after the first dilation of a dominant stenosis, the survival free of liver transplantation rate was 81%, and after 10 years, it was 52%.

LIMITATIONS

Single-center study, no control group, primary end-stage liver disease excluded.

CONCLUSION

Repeated endoscopic balloon dilations of dominant stenoses allow the preservation of a functioning common bile duct for many years.

Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis, and management

Abstract Extraintestinal manifestations occur rather frequently in inflammatory bowel disease (IBD), e.g. ulcerative colitis (UC) and Crohn's disease (CD). The present paper provides an overview of the epidemiology, clinical characteristics, diagnostic process, and management of rheumatic, metabolic, dermatologic (mucocutaneous), ophthalmologic, hepatobiliary, hematologic, thromboembolic, urinary tract, pulmonary, and pancreatic extraintestinal manifestations related to IBD. Articles were identified through search of the PubMed and Embase databases, the Cochrane Library, and the web sites of the European Agency for the Evaluation of Medicinal Products (EMEA) and the US Food and Drug Administration (FDA) (cut-off date October 2009). The search terms 'Crohn's disease', 'inflammatory bowel disease', or 'ulcerative colitis' were combined with the terms 'adalimumab', 'anemia', 'arthritis', 'bronchiectasis', 'bronchitis', 'cutaneous manifestations', 'erythema nodosum', 'extraintestinal manifestations', 'hyperhomocysteinemia', 'infliximab', 'iridocyclitis', 'lung disease', 'ocular manifestations', 'osteomalacia', 'pancreatitis', 'primary sclerosing cholangitis', 'renal stones', 'sulfasalazine', 'thromboembolism', and 'treatment'. The search was performed on English-language reviews, practical guidelines, letters, and editorials. Articles were selected based on their relevance, and additional papers were retrieved from their reference lists. Since some of the diseases discussed are uncommon, valid evidence of treatment was difficult to obtain, and epidemiologic data on the rarer forms of extraintestinal manifestations are scarce. However, updates on the pathophysiology and treatment regimens are given for each of these disorders. This paper offers a current review of original research papers and randomized clinical trials, if any, within the field and makes an attempt to point out practical guidelines for the diagnosis and treatment of various extraintestinal manifestations related to IBD.

Latest and emerging therapies for primary biliary cirrhosis and primary sclerosing cholangitis

Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are the two most common causes of chronic cholestatic liver disease in adults. In PBC, therapy with ursodeoxycholic acid (UDCA) is safe and has been associated with tangible biochemical, histologic, and survival benefits. However, a need for different or adjuvant therapies remains for specific subsets of PBC patients, including those who do not respond to UDCA and those who have advanced histologic disease at presentation. Similarly, beneficial therapies for disease-related symptoms that do not typically respond to UDCA (eg, fatigue and pruritus) are still needed. In contrast to PBC, no medical therapy of proven benefit has been identified for patients with PSC. In PBC and PSC, adequate management of complications of chronic cholestasis is important. For both diseases, liver transplantation is the only curative option.

Prevalence of sclerosing cholangitis in adults with autoimmune hepatitis: a prospective magnetic resonance imaging and histological study

The development of sclerosing cholangitis (SC) is observed in up to 50% of children followed up for autoimmune hepatitis (AIH). In adults, the prevalence is less known, although a recent study found evidence of SC in 10% of AIH patients using magnetic resonance cholangiopancreatography (MRCP). The aim of this study was to assess prospectively the prevalence of SC in adults with AIH. Fifty-nine consecutive patients with AIH diagnosed according to International Autoimmune Hepatitis Group score (women, 71%; mean age, 48 years; cirrhosis, 23%) underwent both MRCP and percutaneous liver biopsy. Twenty-seven patients with cirrhosis of nonbiliary or non-autoimmune etiology served as controls. Fourteen AIH patients (24%) showed mild MRCP abnormalities of intrahepatic bile ducts (IHBDs). None had abnormal common bile duct or convincing evidence of SC on MRCP or biopsy. A diagnosis of overlapping SC was nevertheless retained in one patient with MRCP abnormalities who subsequently developed symptomatic cholestasis despite corticosteroid therapy. Fibrosis score was the only independent parameter associated with bile duct abnormalities on MRCP (odds ratio 2.4; 95% confidence interval 1.4-4.7) and the percentage of patients with IHBD MRCP abnormalities was not different among F3-F4 AIH patients (n = 24) and cirrhotic controls (46% versus 59%; NS).

CONCLUSION

In this cohort of adult patients with AIH, the prevalence of SC was much lower than previously reported (1.7%). Mild MRCP abnormalities of IHBD were seen in a quarter of patients, but these abnormalities resulted from hepatic fibrosis and not SC. In the absence of cholestatic presentation, MRCP screening does not seem justified in adult-onset AIH.

High prevalence of small duct primary sclerosing cholangitis among patients with overlapping autoimmune hepatitis and primary sclerosing cholangitis

BACKGROUND

Overlap syndrome is a term used for overlapping features of autoimmune hepatitis and primary sclerosing cholangitis or primary biliary cirrhosis and for autoimmune cholangitis. We describe a high prevalence of small duct primary sclerosing cholangitis among patients with overlapping autoimmune hepatitis and primary sclerosing cholangitis.

METHODS

We sought to retrieve all patients with overlap syndrome between primary sclerosing cholangitis and autoimmune hepatitis in six university hospitals in Sweden. The revised autoimmune hepatitis scoring system proposed by the International Autoimmune Hepatitis Group was used to establish the diagnosis autoimmune hepatitis. Endoscopic retrograde cholangiography and/or magnetic resonance cholangiography were used to separate the primary sclerosing cholangitis cases diagnosed through liver biopsy into small and large primary sclerosing cholangitis. A histological diagnosis compatible with both autoimmune hepatitis and primary sclerosing cholangitis was required for inclusion.

RESULTS

26 patients fulfilled our criteria for histological overlap of autoimmune hepatitis and primary sclerosing cholangitis, 7 (27%) of which had small duct primary sclerosing cholangitis. The reliability of the diagnosis small duct primary sclerosing cholangitis was supported by a very close similarity between small and large duct primary sclerosing cholangitis patients in clinical and laboratory data, and by a poor response to immunosuppressive therapy in the small duct primary sclerosing cholangitis patients. Patients with large duct overlap syndrome had a good response to immunosuppressive therapy. In both groups, our limited experience from ursodeoxycholic acid was largely poor.

CONCLUSIONS

Small duct primary sclerosing cholangitis is prevalent in the overlap syndrome between autoimmune hepatitis and primary sclerosing cholangitis.

A retrospective single-center review of primary sclerosing cholangitis in children

BACKGROUND & AIMS

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation and progressive bile duct fibrosis. There are limited data on pediatric PSC.

METHODS

We performed a retrospective chart review of 47 pediatric patients with PSC.

RESULTS

The mean age at diagnosis was 11 +/- 4.9 years. Symptoms occurred before presentation in 81% of patients; inflammatory bowel disease was found in 59% and autoimmune hepatitis (overlap syndrome) in 25% of patients. Magnetic resonance cholangiography revealed both extrahepatic and intrahepatic, isolated intrahepatic, isolated extrahepatic, and no biliary involvement (small-duct PSC) in 40%, 14%, 10%, and 36%, respectively. Advanced fibrosis (stage >II) was present in 65%. Colonoscopy revealed pancolitis, rectal sparing, and normal findings in 24%, 24%, and 18%, respectively. All patients were treated with ursodeoxycholic acid (UDCA); 9 with overlap syndrome also received immunosuppressants. Fifteen patients without overlap syndrome had positive autoimmune markers and responded to UDCA monotherapy. Liver transplantation was performed in 9 patients (3 with overlap syndrome and 2 with small-duct PSC) at a median time of 7 years after diagnosis. The 10-year posttransplant survival rate was 89%.

CONCLUSIONS

In one of the largest single-center studies of children with PSC, we found that most children with PSC had inflammatory bowel disease or autoimmune overlap and advanced fibrosis at diagnosis. Levels of alanine aminotransferase and gamma-glutamyl transferase were highest in patients with overlap syndrome and lowest in those with small-duct PSC. Levels of serum liver enzymes normalized after therapy with UDCA, including patients with positive autoimmune markers without histologic features of autoimmune hepatitis.

Primary sclerosing cholangitis--what is the difference between east and west?

Primary sclerosing cholangitis (PSC) is a chronic, progressive, cholestatic liver disease characterized by inflammation and fibrotic obliteration of the hepatic biliary tree. It is commonly associated with inflammatory bowel disease (IBD). A number of complications can occur which require special consideration, the most important of which is the development of cholangiocellular carcinoma (CCC). Unfortunately, no medical therapy is currently available for the underlying liver disease. Liver transplantation is an effective, life-extending option for patients with advanced PSC. Geographical variations between East and West include a second peak for age with a lower association with IBD in a Japanese population and female predominance in a lone study from Turkey. The clinical and biochemical Mayo criteria may not be universally applicable, as different patients show variations regarding the initial presentation and natural course of the disease. Directing research towards explaining these geographical differences and understanding the pathogenesis of PSC is required in order to develop better therapies for this devastating disease.

Magnetic resonance cholangiopancreatography: current use and future applications

Magnetic resonance pancreatography (MRCP) is now established as a robust noninvasive tool for the evaluation of biliary and pancreatic pathology. Its diagnostic performance is comparable with endoscopic retrograde cholangiopancreatography without the associated risks. This article aims to familiarize the reader with the technique, clinical indications, and limitations of the investigation. Common pitfalls in interpretation also are addressed. Emerging applications and techniques are discussed that include recent advances in technology and the development of functional imaging.

New insights into autoimmune liver diseases

Autoinflammatory liver disease represents an important aspect of global hepatological practice. The three principal disease divisions recognized are autoimmune hepatitis, primary sclerosing cholangitis and primary biliary cirrhosis. Largely, but not exclusively, these diseases are considered to be autoimmune in origin. Increased recognition of outlier and overlap syndromes, changes in presentation and natural history, as well as the increased awareness of IgG4-associated sclerosing cholangitis, all highlight the limitations of the classic terminology. New insights continue to improve the care given to patients, and have arisen from carefully conducted clinical studies, therapeutic trials, as well as genetic and laboratory investigations. The challenges remain to treat patients before liver injury becomes permanent and to prevent the development of organ failure.

Primary sclerosing cholangitis - What is the difference between east and west?

Primary sclerosing cholangitis (PSC) is a chronic, progressive, cholestatic liver disease characterized by inflammation and fibrotic obliteration of the hepatic biliary tree. It is commonly associated with inflammatory bowel disease (IBD). A number of complications can occur which require special consideration, the most important of which is the development of cholangiocellular carcinoma (CCC). Unfortunately, no medical therapy is currently available for the underlying liver disease. Liver transplantation is an effective, life-extending option for patients with advanced PSC. Geographical variations between East and West include a second peak for age with a lower association with IBD in a Japanese population and female predominance in a lone study from Turkey. The clinical and biochemical Mayo criteria may not be universally applicable, as different patients show variations regarding the initial presentation and natural course of the disease. Directing research towards explaining these geographical differences and understanding the pathogenesis of PSC is required in order to develop better therapies for this devastating disease.

The challenges in primary sclerosing cholangitis--aetiopathogenesis, autoimmunity, management and malignancy

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease, characterized by progressive inflammation and fibrosis of the bile ducts, resulting in biliary cirrhosis and is associated with a high risk of cholangiocarcinoma. The majority of patients are young, male and have coexisting inflammatory bowel disease. PSC is found with a prevalence of 10/100,000 in Northern European populations. The pathophysiology of PSC is a complex multistep process including immunological mechanisms, immunogenetic susceptibility and disorders of the biliary epithelia. The diagnosis is primarily based on endoscopic cholangiography although magnetic resonance imaging is increasingly used; biochemistry and immunoserology as well as histology play only a minor role. Due to the high risk of developing cholangiocarcinoma and also other tumours of the GI tract, surveillance strategies are essential, however they have yet to be established and evaluated. Biochemical parameters, clinical risk factors, endoscopic procedures and imaging techniques contribute to the early identification of patients at risk. Since medical therapy of PSC with ursodeoxycholic acid does not improve survival, to date, liver transplantation is the only option with a cure potential; if transplantation is accurately timed, transplanted PSC patients have an excellent rate of survival. However if cholangiocarcinoma is detected, a curative treatment is not possible in the majority of cases. The present review critically summarizes the current knowledge on the aetiopathogenesis of PSC and gives an overview of the diagnostic approaches, surveillance strategies and therapeutic options. Primary sclerosing cholangitis is a disease of unknown aetiology and without any further curative treatment options apart from liver transplantation. Therefore it may be regarded as the greatest challenge in hepatology today.

Current diagnosis and management of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is an important liver disease with major morbidity and mortality. The diagnosis of PSC is confirmed by magnetic resonance cholangiopancreaticography, and endoscopic retrograde cholangiopancreaticography is performed in patients needing therapeutic endoscopy. As a result of the unknown cause of the disease, current medical therapies are unsatisfactory. Nevertheless, high-dose ursodeoxycholic acid should be recommended for treatment of PSC patients because there is a trend toward increased survival. Dominant bile duct stenoses should be treated endoscopically. However, liver transplantation continues to be the only therapeutic option for patients with advanced disease. Estimation of prognosis and timing of liver transplantation should be determined individually for each PSC patient on the basis of all results. The diagnosis and treatment of cholangiocarcinoma (CC) still remain a challenge in PSC patients. Early diagnosis of CC certainly is a prerequisite for successful treatment with surgical resection or innovative strategies such as neoadjuvant radiochemotherapy with subsequent orthotopic liver transplantation. Therefore, endoscopic techniques such as cholangioscopy and/or intraductal ultrasound may be useful diagnostic tools in patients with stenoses suspicious for malignancy.

Endoscopy in the management of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic, cholestatic liver condition characterized by progressive fibrosis and destruction of the intra- and extrahepatic biliary tree. PSC has a clear association with inflammatory bowel disease and is often progressive, leading to cirrhosis and end-stage liver failure. For many patients, liver transplantation offers the only hope of long-term survival. No effective medical treatment exists, and therapy is often aimed at treating complications of the disorder, including dominant biliary strictures, which may cause symptomatic jaundice, cholangitis, and pruritus. Studies on endoscopic therapy (eg, biliary dilation and/or stent insertion) have shown favorable results, although most studies have been small, retrospective, and uncontrolled. Up to 20% of patients with PSC develop cholangiocarcinoma; however, distinguishing between cholangiocarcinoma and benign strictures can be difficult. Ideally, randomized trials are required to determine the safest and most effective endoscopic management for symptomatic dominant strictures.

Multidisciplinary approach to benign biliary strictures

The various approaches used for the management of patients with benign biliary strictures are justified by the diverse nature, clinical presentation, and severity of these strictures. Benign biliary strictures are most commonly postoperative, a consequence of injury during laparoscopic cholecystectomy or fibrosis after biliary duct-to-duct or bilioenteric anastomoses (ie, liver transplantation). Less frequently, benign strictures are due to chronic pancreatitis or other nonmalignant diseases, including external compression, parasites, stone perforation, and infections. Because of their peculiar pathogenesis, localization, and short extension into the bile duct, the majority of these strictures can be approached by operative treatments such as surgical bypass and endoscopic--or radiological--dilation. In contrast, primary sclerosing cholangitis (PSC) is a systemic disease with immune-mediated inflammation and subsequent fibrosis of the bile ducts with the development of multiple strictures due to an "intrinsic" liver disease; thus, medical therapy and pharmacologic research are mainly focused on the treatment of PSC rather than other benign biliary strictures. However, none of the previously mentioned benign strictures has a univocal and sole treatment. Any attempt to identify a standard treatment for all the strictures is questionable, inconclusive, and most likely useless due to the diversity of patients and diseases. Gastroenterologists, radiologists, and surgeons work in tight collaboration, not in competition, to individualize the patients' treatment. The morphology and extension of the stricture, its location, the theoretical pathogenesis (eg, intrinsic strictures, strictures due to inflammation and fibrosis after bile leak, ischemic lesions), the patients' specific characteristics (comorbidity and history of prior surgery, including enterobiliary anastomoses and gastric resection), and preferences should indicate the treatment that may offer the patient major benefits with a lower complication rate. Unfortunately, in most of the cases, choosing between different treatments is more likely based on local availability than their actual effectiveness and indication.

Correlation between findings on MRCP and gadolinium-enhanced MR of the liver and a survival model for primary sclerosing cholangitis

Primary sclerosing cholangitis is a chronic, progressive disease of inflammation and fibrosis of the bile ducts. The ability to predict survival is important for appropriate management and treatment decisions. The purpose of this study was to examine the relationship between specific findings on the enhanced magnetic resonance imaging (MRI) examination of the liver and the corresponding magnetic resonance cholangiopancreatogram (MRCP) and a survival model for primary sclerosing cholangitis (PSC), the Mayo Risk Score. During a five-year period, 47 patients with primary sclerosing cholangitis were identified who had a complete MRI/MRCP examination. The extent of anatomical changes of the biliary tree and the degree of peribiliary enhancement in the hepatic parenchyma were compared with the Mayo Risk Score for each patient. Peribiliary enhancement was present to a varying extent in 38 of 47 cases of PSC. Peribiliary enhancement 3 min after gadolinium administration had a weak correlation with the Mayo Risk Score (analysis of variance P<0.01, Pearson correlation r=0.37). No statistically significant relationship between the severity of extrahepatic or intrahepatic duct changes and the Mayo Risk Score was found (analysis of variance P=0.24, P=0.38, respectively). Although biliary tree changes on MRCP aid in the diagnosis of PSC, they do not correlate with survival, as predicted by the Mayo Risk Score. Peribiliary enhancement on MRI of the liver is a finding occurring to a variable extent in primary sclerosing cholangitis but does not correlate significantly with survival.

The patient with unexplained elevated serum liver enzymes

The pattern of elevated serum liver enzymes in symptomatic or asymptomatic patients allows for an initial classification of liver diseases into cholestatic or hepatocellular diseases. A female patient with extrahepatic cholestasis due to segmental bile duct strictures and a localized mass lesion within the pancreas is presented. Although many diagnostic procedures were performed in this case the diagnosis was not obtained before surgical laparotomy was initiated with bioptic sampling from bile ducts, lymph nodes and pancreatic tissue. Microscopic examination of the specimen revealed extensive biliary and pancreatic scarring together with periductal infiltrates composed of lymphocytes and plasma cells consistent with sclerosing cholangitis in systemic autoimmune pancreatitis. The patient completely recovered upon treatment with prednisone and azathioprine. The difficult approach to the final diagnosis is discussed in light of established and modern diagnostic tools.

Sclerosing cholangitis

PURPOSE OF REVIEW

Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by strictures of the biliary tree complicated by cirrhosis and cholangiocarcinoma. It is immune mediated, although the precise aetiology remains unknown.

RECENT FINDINGS

Research into etiopathogenesis and epidemiology, diagnosis of cholangiocarcinoma, associations with inflammatory bowel disease and autoimmune pancreatitis, and medical therapy are discussed.

SUMMARY

Multiple gene polymorphisms associated with primary sclerosing cholangitis have been investigated. Common inflammatory bowel disease-associated polymorphisms do not confer any susceptibility to primary sclerosing cholangitis; the role of intercellular adhesion molecule-1 gene polymorphisms and CCR5 mutations remain unclear. Elevated IgG4 has been demonstrated in a subgroup of primary sclerosing cholangitis patients, which may indicate an overlap with autoimmune pancreatitis and possible responsiveness to steroids. Biliary brush cytology may assist in diagnosis of cholangiocarcinoma, although further clinical indicators are required. Animal studies suggest the superiority of 24-norursodeoxycholic acid over ursodeoxycholic acid in reducing histological disease progress; translational studies in humans are now required.

Cholestasis and cholestatic syndromes

PURPOSE OF REVIEW

This review focuses on the recent advances in cholestatic liver diseases. While there is an emphasis placed on translational and treatment-focused studies, basic science studies with the greatest impact on the field are also covered.

RECENT FINDINGS

Highlights include new discoveries for the role of the farsenoid X receptor and sodium-dependent taurocholate cotransporting polypeptide; new insights into the pathogenesis of progressive familial intrahepatic cholestasis type 1, biliary atresia, intrahepatic cholestasis of pregnancy, and primary biliary cirrhosis; new information for assessing prognosis in biliary atresia and primary biliary cirrhosis; and important clinical trials in intrahepatic cholestasis of pregnancy, primary biliary cirrhosis and primary sclerosing cholangitis.

SUMMARY

The studies of 2006 have furthered our understanding of cholestasis and cholestatic syndromes. While we continue to add to our knowledge of pathogenesis and treatment for many of these diseases, much work remains.

Changes over a 20-year period in the clinical presentation of primary sclerosing cholangitis in Sweden

OBJECTIVE

The use of magnetic resonance cholangiopancreaticography (MRCP) as a non-invasive diagnostic tool for primary sclerosing cholangitis (PSC), together with increased clinical awareness of the disease, has led to earlier diagnosis. The aim of this study was to investigate the clinical presentation of PSC including its association with inflammatory bowel disease (IBD) and the development of cholangiocarcinoma at one centre over an observation period of 20 years.

MATERIAL AND METHODS

All patients with well-defined PSC, diagnosed after 16 years of age and treated at Huddinge University Hospital between 1984 and 2004, were included in the study (n=246). PSC and IBD characteristics were retrieved from the patients' medical records. The patients were subdivided according to the date of diagnosis: 185 PSC patients diagnosed before 30 October 1998 were compared with 61 patients diagnosed after that date.

RESULTS

Patients diagnosed after 1998 were significantly older at diagnosis (mean age 41 versus 37 years) and presented fewer symptoms (47% versus 63%) as well as a lower frequency of coexisting IBD (69% versus 82%). In the whole group, women had significantly more symptoms than men, particularly pruritus (p<0.05).

CONCLUSIONS

The clinical spectrum of PSC in Sweden has changed over the past 20 years; today, PSC patients are older at diagnosis and associated IBD is less frequent.

Gastroenterology and hepatology clinical research update: 2005-2006

This review highlights areas of clinical research in gastroenterology and hepatology that were published predominantly in the journal Clinical Gastroenterology and Hepatology during the last year and were summarized during the American Gastroenterological Association Presidential Plenary Session in May 2006. The topics included eosinophilic esophagitis in children, detecting high-grade dysplasia or carcinoma in Barrett's esophagus, advances in management of celiac disease with elemental diet or gluten predigestion, the safety of NSAIDs in inflammatory bowel disease, the role of steroids in development of abscesses, prognosis of colorectal cancer associated with inflammatory bowel disease, screening for familial colorectal cancer in apparently sporadic disease, a new syndrome of familial colorectal cancer, new drugs in the treatment of chronic constipation and obesity, hepatoma risk factors and underserved racial/ethnic groups, and the application of new imaging and biology in diagnosis of gastroenterological disorders.