Hepatolithiasis with biliary ascariasis--a case report

Clinical, histopathological, and immunohistochemical spectrum of hepatolithiasis: a tertiary care center-based study from north India

Hepatolithiasis (HL), an uncommon disease among Indians, occurs due to a complex interplay of various structural and functional factors. We retrospectively evaluated the clinical and histopathological spectrum of HL (N = 19) with immunohistochemical evaluation for biliary apomucins and canalicular transporter proteins, both crucial for lithogenesis. Nineteen surgically resected cases were included. Histopathology was systematically evaluated. Immunohistochemistry for apomucins (MUC1, MUC2, MUC4, MUC5AC, and MUC6) and canalicular transporter proteins (BSEP and MDR3) was applied to all cases. The median age was 51 years with female preponderance (F:M = 1.4:1). The stone was cholesterol-rich in 71.4% and pigmented in 28.6% (n = 14). Histopathology showed variable large bile-duct thickening due to fibrosis and inflammation with peribiliary gland hyperplasia. Structural causes (Caroli disease, choledochal cyst, and post-surgical complication) were noted in 15.8% of cases (secondary HL). Expression of gel-forming apomucin MUC1, MUC2, and MUC5AC was seen in either bile duct epithelia or peribiliary glands in 84.2%, 10.5%, and 84.2% cases respectively. Loss of canalicular expression of MDR3 was noted in 42.1% of cases while BSEP was retained in all. Primary HL in the north Indian population can be associated with the loss of MDR3 expression (with retained BSEP) and/ or a shift in the phenotype of biliary apomucins to gel-forming apomucins. The former factor alters the bile acid/ phospholipid ratio while the latter parameter promulgates crystallization. In conjunction, these factors are responsible for the dominantly cholesterol-rich stones in the index population.

Pathogenesis and Management of Hepatolithiasis: A Report of Two Cases

Hepatolithiasis or primary intrahepatic stones are prevalent in the Far-East countries such as Korea, Japan and Taiwan. It has been associated with helminthiasis, bacterial infections, environmental and dietary factors. Despite high prevalence of helminthiasis like ascariasis, poor environmental condition and low protein diet, India and Middle-East countries have a low incidence of hepatolithiasis. We report two cases of hepatolithiasis associated with bacterial infections and were surgically managed. The first case is a 45-year-old female presenting with upper abdominal pain and fever. She had multiple calculi in intrahepatic biliary radicles, common bile duct, common hepatic duct and gall bladder. She was managed by cholecystectomy, left lateral liver sectionectomy, choledochoscopy assisted stone clearance of the residual liver and Roux-en-Y hepatico-jejunostomy. The second case is a 60-year-old female presenting with epigastric pain and fever and past history of cholecystectomy for cholelithiasis. She had multiple right and left intrahepatic calculi and managed by left lateral liver sectionectomy with excision of CBD and Roux-en-Y hepatico-jejunostomy. Both the cases showed growth of bacteria in the culture of the intraoperatively collected bile.

Intrahepatic Duct Stones Harboring Ascariasis Ova: A Case Report

Ascariasis lumbricoides is one of the most common helminthic infestations in humans. Despite the fact that the prevalence of ascariasis in developed countries has been decreasing, biliary ascariasis can cause serious complications, such as acute cholangitis, pancreatitis, and liver abscess. Here we presented a rare ascariasis-related complication-hepatolithiasis.A 60-year-old female patient had symptoms of recurrent cholangitis. Abdominal computed tomography scan revealed left intrahepatic duct stones with left liver lobe atrophy. Endoscopic retrograde cholangiopancreatography was performed, but the stones could not be removed due to left main intrahepatic duct stenosis. The patient was treated with left hemi-hepatectomy. Unexpectedly, Ascaris ova were found on the histopathological examination. She received antihelminthic therapy orally and was on regular follow-up without any complications.Our study indicates that clinicians should be aware of biliary ascariasis in patients with hepatolithiasis, though not living in endemic areas.

Right hepatolithiasis and abnormal hepatic duct confluence: more than a casual relation? Am J Surg. 2011;201:514-518. [PMID: 20870207 DOI: 10.1016/j.amjsurg.2010.02.019]

BACKGROUND

Hepatolithiasis (HL) is a rare disease in Western countries. The aim of our study was to investigate a possible relation between the development of right HL and abnormalities of the hepatic duct confluence.

MATERIAL AND METHODS

Fourteen patients who presented with localized right-sided HL were included in this study. The anatomy of hepatic duct confluence in this group of patients was analyzed and compared with the anatomy of hepatic duct confluence in the general population.

RESULTS

The Presence of a shift of 1 of the 2 sectorial right ducts was significantly associated with right-sided HL (P = .003).

CONCLUSIONS

The shift of a sectorial right duct must be considered as one of the anatomic causes of HL. This finding must be considered when surgical treatment of HL is planned.

Comparative study on presentation of biliary ascariasis with dead and living worms

BACKGROUND/AIM

Ascariasis is a common parasitic infestation in Asia and Latin America. The most serious presentation is biliary and pancreatic ascariasis (BPA). The aim of the present study was to compare the clinical presentation of BPA with dead worms with that with living worms.

MATERIALS AND METHODS

We included 138 consecutive cases of BPA that occured during the period January 2005 to July 2009. All the patients had endoscopically proven BPA consisting of living or dead worms. Comparison was done by chi-square and independent t tests.

RESULTS

The age (mean +/- SD) of the patients was 36.8 +/- 16.1 years. Prevalence ratio between male and female patients was 1:5. Ninety eight patients contained living worms and 40 had dead worms. Males were more prone to develop dead worm BPA. The commonest presentation was biliary colic (131; 94.9%); others were acute cholangitis (30; 21.7%), obstructive jaundice (19; 13.8%), choledocholithiasis (20; 14.5%), acute pancreatitis (10; 7.2%), acute cholecystitis (6; 4.3%), liver abscess (2; 1.4%), hepatolithiasis (3; 2.2%), stricture of common bile duct (2; 1.4%), pancreatic abscess (1; 0.7%) and cirrhosis of liver (1; 0.7%). Choledocholithiasis, hepatolithiasis, liver abscess and cirrhosis were associated only with dead worms. We could successfully remove all the worms with endoscopic interventions, but 5 patients required surgical intervention as there were strictures and stones within the biliary tree or Ascaris were in gallbladder. Recurrences of stone and cholangitis occurred only in those with dead worms.

CONCLUSION

Biliary ascariasis with dead worms is more dangerous than that with living worms. Endoscopic or surgical intervention may be required repeatedly in those with dead worms.

Proteomic analysis of livers of patients with primary hepatolithiasis

Primary hepatolithiasis or intrahepatic calculi (IHC), which is characterized by the formation of gallstones in the intrahepatic bile duct, is an intractable liver disease and suspected to be one of the causes of cholangiocellular carcinoma. To obtain an insight into the disease, we performed proteomic analysis of liver tissue specimens of paired affected and unaffected hepatic segments from patients with primary hepatolithiasis by two-dimensional gel electrophoresis followed by identification of proteins. For the specimens from the unaffected segments, 125 spots out of 613 spots were identified, defining 83 unique protein names. For the specimens from the affected segments, 102 spots out of 671 spots were identified, defining 74 unique protein names. To further precisely compare, we used two-dimensional fluorescence difference gel electrophoresis. Consequently we identified 12 up-regulated proteins and 21 down-regulated proteins. The up-regulated proteins contained the proteins related to liver fibrosis and to cellular oxidoreduction. The down-regulated proteins contained RAF kinase inhibitor protein, chaperonin and proteins related to principal liver function.