THE SPECTRUM OF CHOLESTATIC HEPATIC DISEASE

Stauffer's Syndrome in Pancreatic Cancer: First Case Report

Stauffer's syndrome is a rare paraneoplastic syndrome classically associated with renal cell carcinoma. It presents as abnormal hepatic panel in the absence of hepatic disease, which improves with treatment of the cancer and worsens with recurrence. Here, we describe a case of hepatic panel abnormalities in a patient with pancreatic cancer with no evidence of metastatic disease to the liver, primary hepatobiliary etiology, or clear offending medications. We believe this to be the first reported case of Stauffer's syndrome in patients with pancreatic cancer.

Risk factors for gallbladder cancer and cholangiocarcinoma: similarities, differences and updates

INTRODUCTION

Far-ranging variation in the incidence of gallbladder cancer (GBC) and cholangiocarcinoma (CCA) in different geographic regions on the globe may reflect the risk factor distribution for these tumors

METHODS

The authors give a comprehensive review on the known risk factors for GBC and CCA, and analyze both similarities and differences between the risk factors for the two main types of biliary cancer

DISCUSSION AND CONCLUSION

Leading risk factors for GBC include gallstones, female gender, and advancing age. Primary sclerosing cholangitis, nitrosamine exposure, choledochal cysts, Clonorchis sinensis and Opisthorchis viverrini represent important risk factors for CCA, although a specific risk factor cannot be identified for many patients. While both cancers affect mostly individuals in their sixth decade or older, CCA has a male predominance and GBC--a predilection for females. Although the current level of understanding of the molecular pathogenesis of GBC and CCA at the interface with specific risk factors is significantly lower than for other gastrointestinal malignancies, it continues to evolve and may soon open new avenues for the therapy of biliary cancers.

Cholangiocarcinoma: natural history, treatment, and strategies for surveillance in high-risk patients

Cholangiocarcinoma is a primary malignancy of biliary epithelium. Risk factors for cholangiocarcinoma include primary sclerosing cholangitis and other conditions that produce chronic inflammation of the biliary tree. The diagnosis of cholangiocarcinoma can be elusive; it is often not made until advanced disease is present and at a stage when a curative surgical resection is not feasible. Currently used diagnostic modalities include serum and bile tumor markers, radiologic and endoscopic imaging, and pathologic analysis. Surveillance strategies to increase the chance of early diagnosis should be strongly considered in individuals at high risk for cholangiocarcinoma. Patients with long-standing primary sclerosing cholangitis would be the ideal candidates for a screening program.

Primary sclerosing cholangitis

Primary sclerosing cholangitis is a condition of unknown cause. It is recognized by liver dysfunction and its characteristic radiologic appearance, which is related to portal tract inflammation, bile duct proliferation, and periductal fibroses involving small intrahepatic and large extrahepatic ducts. The disease lasts about 10 years from the time of diagnosis. Primary sclerosing cholangitis is recognized by abnormal results on routine liver function tests or by the development of clinical jaundice. An autoimmune cause has been suggested because of its strong association with inflammatory bowel disease, certain antigens, AIDS, and immunoregulatory abnormalities. Results of medical management of sclerosing cholangitis have been disappointing. Immunosuppressive drugs, copper chelating agents, and antibiotics have failed to alter progression of the disease. Colectomy in patients with inflammatory bowel disease also has no influence. The judicious use of dilations of strictures, bypass procedures, or resection can palliate jaundice in patients with primary sclerosing cholangitis, but liver transplantation is the definitive treatment. Because palliative operations increase the hazards of liver transplantation, percutaneous dilations and stentings are preferred initially. Cirrhosis and portal hypertension are indications for transplantation. In the future, transplantation may be indicated earlier in the course of the disease.

Effect of proctocolectomy for chronic ulcerative colitis on the natural history of primary sclerosing cholangitis

The effect of proctocolectomy on the primary sclerosing cholangitis that frequently is associated with chronic ulcerative colitis in patients with both conditions is unknown. We have studied prospectively the progression of clinical, biochemical, cholangiographic, and hepatic histologic features in 45 patients with both primary sclerosing cholangitis and chronic ulcerative colitis to compare these variables in the 20 patients who had undergone proctocolectomy with the 25 who had not. The two groups were similar initially with regard to clinical, biochemical, cholangiographic, and hepatic histologic findings. All patients were followed for a minimum of 1 yr and overall duration of follow-up was similar in both groups (4.1 vs. 3.9 yr). Clinically, new onset of hepatomegaly, splenomegaly, esophageal varices, and ascites did not differ in patients with and without proctocolectomy. Biochemically, the serial changes in bilirubin, alkaline phosphatase, aspartate aminotransferase, prothrombin time, and albumin were similar. Histologic progression on liver biopsy did not differ between groups, nor did changes on serial cholangiograms. Proctocolectomy also had no effect on survival. We conclude that proctocolectomy for chronic ulcerative colitis has no beneficial effect on the primary sclerosing cholangitis in patients with both diseases.

Primary carcinoma of the gall bladder associated with ulcerative colitis

The report concerns a case of primary carcinoma of the gall bladder in a 53 year old man, who, 13 years previously underwent a pan-proctocolectomy for ulcerative colitis. Previous reports are reviewed, highlighting the difficulty of early diagnosis.

Histological features of sclerosing cholangitis in patients with chronic ulcerative colitis

Primary sclerosing cholangitis was diagnosed radiologically in 16 of 681 patients (2.2%) with chronic ulcerative colitis in a follow up study at the gastroenterology unit in Oxford. On the basis of established histological criteria, the liver biopsy was considered diagnostic in only half of the cases. The histological findings in these cases were therefore reassessed to determine whether the accuracy of biopsy diagnosis could be improved. The most common specific histological feature was periductal concentric fibrosis of small interlobular bile ducts, even in the absence of inflammation. Other common features were bile ductular proliferation associated with diminution or absence of interlobular bile ducts. Degeneration of bile duct epithelium and diffuse infiltration of portal tracts by mononuclear cells and polymorphonuclear leucocytes were accompanying features. Piecemeal necrosis without rosette formation was found in about half the biopsies. When all these features were considered together a biopsy diagnosis of primary sclerosing cholangitis was established in 14 of 16 cases.

Primary carcinoma of the gallbladder associated with chronic inflammatory bowel disease

Patients with chronic inflammatory bowel disease have an increased risk of developing carcinoma of the bile ducts. This risk is highest in those with a long history of colitis and total involvement of the colon. The majority of these biliary tract cancers involve the extrahepatic or intrahepatic bile ducts. Occasionally, however, the gallbladder is the site of origin of the tumour. We report three cases of primary carcinoma of the gallbladder complicating chronic inflammatory bowel disease. In two, there was universal chronic ulcerative colitis and in one, Crohn's ileocolitis.

Chronic graft-versus-host syndrome in man. A long-term clinicopathologic study of 20 Seattle patients

This study of chronic graft-versus-host disease (GVHD) describes the clinical, pathologic and laboratory features, and the causes of morbidity and mortality in 20 patients who received allogeneic marrow transplants from HLA identical sibling donors. Chronic GVHD is a pleiotrophic syndrome with variability in the time of onset, organ systems involved and rate of progression. The clinical-pathologic features resemble an overlap of several collagen vascular diseases with frequent involvement of the skin, liver, eyes, mouth, upper respiratory tract, esophagus and less frequent involvement of the serosal surfaces, lower gastrointestinal tract and skeletal muscles. Major causes of morbidity are scleroderma with contractures and ulceration, dry eyes and mouth, pulmonary insufficiency and wasting. Chronic GVHD has features of immune dysregulation with elevated levels of eosinophils, circulating autoantibodies, hypergammaglobulinemia and plasmacytosis of viscera and lymph nodes. In this study, three patients had limited chronic GVHD with relatively favorable prognosis characterized by localized skin involvement and/or hepatic disease without chronic aggressive histology. Most patients, however, had extensive disease with a progressive course. Survival was largely determined by the presence or absence of serious recurrent bacterial infections. The over-all severity of disease was best assessed by using the Karnofsky performance rating.

Cholangiographic abnormalities in ulcerative colitis associated pericholangitis which resemble sclerosing cholangitis

Cholangiographic abnormalities in asymptomatic patients with pericholangitis and long-standing ulcerative colitis, which resemble sclerosing cholangitis, have not been previously reported. Endoscopic retrograde cholangiography (ERC) performed in one such patient suggesting intrahepatic sclerosing cholangitis stimulated the study of seven additional patients with largely asymptomatic pericholangitis. In seven of these eight patients, ERC demonstrated abnormalities which resembled sclerosing cholangitis. These consisted of beading and strictures mainly of the intrahepatic biliary tree (IHB). In two of the eight, the common bile duct was involved. In one, this was associated with histologic progression to cirrhosis and frank cholangitic episodes even though the initial clinical presentation and hepatic histology 2 1/2 years earlier suggested only pericholangitis. We therefore conclude that bile duct abnormalities resembling sclerosing cholangitis may be demonstrated cholangiographically in patients with ulcerative colitis who present with the typical picture of pericholangitis.

A review of lobular, portal, and periportal hepatitis. Interpretation of biopsy specimens without clinical data

This representation, in which a recently adopted terminology is used, represents a compilation of clinical diagnoses that must be considered whenever a morphologic diagnosis of lobular, portal, or periportal hepatitis has been made. Also described are the morphologic findings that may enable the pathologist to list, without knowledge of clinical data, the suspected clinical conditions in an order of likelihood.

Chronic liver disease associated with childhood ulcerative colitis

In a series of 301 patients with ulcerative colitis forty-eight developed the disease before the age of 20. In this group of forty-eight patients there were four cases of serious chronic liver disease as compared with a total of seven cases of chronic liver disease in the whole series. The hepatic lesions in the patients developing colitis in childhood were unrelated to the extent, duration or severity of the colitis but colitis in very early life appeared to predispose to liver disease subsequently.

Ulcerative colitis and carcinoma of the proximal bile ducts

In a review of 103 patients with carcinoma of the proximal bile ducts, eight patients were noted to have had ulcerative colitis also. This finding is strongly suggestive of a specific association between the two diseases. In three of the patients, carcinoma developed several years after proctocolectomy. Seven of the eight patients were significantly younger than the median age of the group as a whole, but no other apparent difference was noted between those with ulcerative colitis and the remainder of the group.

Controlled study of autoimmunization against liver in inbred rat strains

By prolonged immunization of an inbred rat strain with isologous liver homogenate in Freund's complete adjuvant a low grade autoimmune ;cholangitis' with periductular fibrosis has been demonstrated. The lesion could be transferred to isogeneic animals by serial spleen cell injections and was associated with mild but variable delayed skin sensitivity to a supernatant fraction of the liver homogenate. It is thought to be due to a combined cellular and antibody-mediated immune response, directed against bile duct constituents. Pulmonary (peribronchial) lesions have also been described in the same animals and are considered to be of similar origin and to represent a cross reaction with tissue of similar embryological (entodermal) origin. This appears to be the first description of periductular hepatic fibrosis clearly resulting from an autoimmune reaction and may provide a model for further study of rather similar histological reactions known to occur in man.

Tumors of biliary epithelium and ulcerative colitis

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Chronic cholangitides: aetiology, diagnosis, and treatment

A number of different chronic diseases affect the intrahepatic bile radicles or cholangioles. They include primary and secondary sclerosing cholangitis, primary biliary cirrhosis, chronic cholestatic drug jaundice, atresia, and carcinoma. Aetiological factors include infection, immunological changes, hormones, and congenital defects.Patients with chronic cholestasis have decreased bile salts in the intestinal contents and suffer from a bile salt deficiency syndrome. Failure to absorb dietary fat is managed by a low-fat diet and by medium-chain trigly-cerides which are absorbed in the absence of intestinal bile salts. Fat-soluble vitamin deficiencies are prevented by parenteral vitamins A, D, and K(1). Calcium absorption is defective, and improvement may follow intramuscular vitamin D, medium-chain triglycerides, a low-fat diet, and oral calcium supplements.In partial intestinal bile salt deficiency the anionic bile-salt-chelating resin cholestyramine controls pruritus though steatorrhoea increases. Pruritus associated with total lack of intestinal bile salts is managed by methyl-testosterone or norethandrolone, though the jaundice increases.

Primary sclerosing cholangitis, the biliary tree, and ulcerative colitis

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