ARTICLE REVIEW 5

Author's Name : Massimo Tonolini, Roberto Bianco

Article Title : HIV-related/AIDS cholangiopathy: pictorial review with emphasis on MRCP findings and differential diagnosis 

Journal Name : Clinical Imaging Volume 37

1)   Bibliography

Tonolini, M., & Bianco, R. (2013). HIV-related/AIDS cholangiopathy: Pictorial review with emphasis on MRCP findings and differential diagnosis. Clinical Imaging, 37(2), 219–226. https://doi.org/10.1016/j.clinimag.2012.03.008

2)  Purpose of the Article

    This article is mainly to describe the role of MRCP and other different diagnosis for HIV/AIDS cholangiopathy. 

3)  Brief Description of Procedure and Findings/Results

Ultrasound

Universally, ultrasound becomes as an ideal and valuable modality in HIV patients to visualize the impacted organ like liver and pancreas, but, it has very limited ability to image biliary and pancreatic ducts. On contrary, the dilatation of intra and extra hepatic ducts are accurate findings reported in positive AIDS settings. Therefore, following ultrasound detection of biliary abnormalities in HIV patients, correlation with clinical and laboratory findings and appropriate further investigation should be suggested.
ERCP
Previously, AIDS cholangiopathy was diagnosed based on the visualization of cholangiographic defects through the standard ERCP. The demonstration had been classified according to their type: type I, type II and type III.
MRCP
MRCP of T2 weighted sequences utilize the essential contrast between fluid-filled structures difference.In this sequences, MRCP uses long relaxation time and also the adjacent structures to represent slow moving or static flow of bile duct and pancreatic secretion on a low intensity background. Also, MRCP depicts a cheaper and non-invasive procedure that act as an alternative to ERCP that will allow better visualization of intra and extrahepatic biliary tracts defect. 

4)   Conclusions and Comments

This article has emphasized clearly about AIDS cholangiopathy which can be best diagnosed by using certain modalities especially MRCP. In basis, biliary dilatation and jaundice are common causes of this pathology. It has been proved by magnetic resonance cholangiopancreatography (MRCP) due to its fundamental role in the study of biliary disorders. Thus, ERCP was replaced by MRCP in some conditions because it is quite invasive and becomes demanded when only interventional procedures are indicated. In comparison to ERCP, MRCP  is better in terms of the visibility of tight stricture; it is not opacified and easy to be seen. Also, it can even imaged the intra and extra-hepatic biliary tract clearly.

5)   Opinion of the Article

Personally, i think this article is at its best to describe briefly the pathology of AIDS cholangiopathy. It had justified some appearances on radiographic images that indicated a person to have this disease. At the same this, this article was compared different modalities used in the diagnosis directly set the gold standard to image AIDS cholangiopathy. Thus, I had rule out that MRCP is the best modalities as been mentioned in the article.

APPEARANCE OF PATHOLOGY ON RADIOGRAPHS/IMAGES

Figure 1: A 35-year-old woman with HIV–hepatitis C; (A) Ultrasound detects moderately dilated CBD with distal tapering, (B, and C) MRCP of CBD dilatation with papillary stenosis (arrowheads),(D) Contrast-enhanced MRI confirms absence of solid periampullary tissue

Figure 2: 44-year-old man with advanced AIDS; (A) thick-slab and (B) MIP-reformatted thin-slice MRCP images show irregular “beaded” appearance of the intrahepatic biliary tree. Pancreas divisum (main pancreatic duct in continuity with the Santorini) is noted as an incidental finding (arrowhead).

Figure 3: A 48-year-old HIV-positive man;(A) Axial T2-weighted MR image shows

irregular intrahepatic ductal dilatation, (B) Thick-slab and (C) MIP-reformatted thin-slice MRCP acquisitions detect segmental portions of the intrahepatic biliary tree of both lobes involved by multiple alternating stenosis and saccular dilatations.

ARTICLE REVIEW 4

1) NAME OF ARTICLE/TEACHING FILE 

Progressive HIV-associated Cholangiopathy in an HIV Patient Treated with Combination Antiretroviral Therapy.

2) HTTP OF THE ARTICLE/TEACHING FILE

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5088554/


3) PATIENT HISTORY

A 37-year-old Japanese man, who has sex with men and presenting with neurosyphilis, pneumococcal pneumonia, and HIV infection. The patient had no history of drug use or alcoholism. 


4) TYPE OF IMAGE

MRI of liver


5) REPORTED DIAGNOSIS AND/OR CASE FINDINGS 

Given the findings, the patient's liver dysfunction was suspected to be HIV-associated cholangiopathy.


6) EXPLANATION OF CASE FINDINGS/PERTINENT FACTS

He was started on a cART regimen of tenofovir, emtricitabine, and darunavir according to Japan's national protocol for AIDS therapy. The HIV viral load became undetectable after 4 months of therapy, and the CD4 cell count increased to over 200 cells/μL within 2 months of cART initiation. Following the increase in the CD4 cell count, the patient's hepatic and biliary enzyme levels normalized immediately. The elevation of T-bil was not observed in his clinical course. Therefore, they eventually diagnosed the patient's liver dysfunction to be HIV-associated cholangiopathy.


7) RESOURCE USED

Imai K., Misawa K., Matsumura T., Fujikura Y., Mikita K., Tokoro M., Maeda T., Kawana A. (2016). Progressive HIV-associated Cholangiopathy in an HIV Patient Treated with Combination Antiretroviral Therapy. Internal Medicine, 55(19), 2881-2884. doi:10.2169/internalmedicine.55.6826

APPEARANCE OF PATHOLOGY ON RADIOGRAPHS/IMAGES

Figure 1: Magnetic resonance imaging shows an intrahepatic bile duct stricture and pruned-tree appearance, mainly in the anterior segment of the right hepatic lobe (a, b). Magnetic resonance imaging at 15 months after the initiation of cART shows further focal dilatation in the intrahepatic bile duct (arrowhead) (c, d).

ARTICLE REVIEW 3

Author's Name : N. Vermania, M. Kanga,, N. Khandelwala, P. Singha, Y.K. Chawlab

Article Title : MR Cholangiopancreatographic Demonstration of Biliary Tract Abnormalities in AIDS Cholangiopathy: Report of Two Cases.

Journal Name : The Royal College of Radiologists.

1)   Bibliography

Vermani, N., Kang, M., Khandelwal, N., Singh, P., & Chawla, Y. K. (2009). MR cholangiopancreatographic demonstration of biliary tract abnormalities in AIDS cholangiopathy: report of two cases. Clinical Radiology, 64(3), 335–338. https://doi.org/10.1016/j.crad.2008.09.002

2)   Purpose of the Article
     

The purpose of this article was to review two different situations in two patients that having the same disease of AIDS Cholangiopathy. Both cases were distinguished using magnetic resonance cholangio-pancreatography (MRCP) modality. Those images produced purposely to see the changes and defects in the biliary tract. 

3)   Brief Description of Procedure and Findings/Results

          In the first case, a patients presented with right upper abdominal pain and jaundice was assessed. Initially, two serological test was conducted to confirm the seropositivity of HIV. The result of those tests showed increases in certain levels such as bilirubin and alkaline phosphate. The elevation in bilirubin an alkaline phosphate levels were considered as an abnormality to the gallbladder, liver or even bone. Next, an examination of ultrasound was done; there was a mild dilatation of the common bile duct (CBD) illustrated. Similarly, there was an evidence of narrowing appearance at 1.2 cm distally of the CBD. In this case, an MRCP was done by a 1.5 T magnetic resonance imaging (MRI) system of 40 mm sectional thickness with the help of maximum intensity projection (MIP) for a better demonstration of the defection.

             For the second case, it involved a 37 years old man with jaundice and hepatomegaly. As similar to the first case, there was also an increment in the alkaline phosphate levels to show distortion to the biliary system. The man had undergone three different test to validate whether his HIV is positive. As ultrasound examination was carried out, an appearance of hepatomegaly with acute acalculous cholecystitis and dilated CBD were indicated. After two days of sonographic procedure, an MRCP was done by using exactly the same sequence pulse as in the first case. It demonstrated dilatation to the CBD that has smooth tapering at the distal part. with smooth tapering in its distal part. As an improvement to the image, multsection axial views were obtained; bulky papilla in duodenum, beaded appearance of biliary ducts and thickening of gall bladder wall were denoted.

4)   Conclusions and Comments

    To summarize, AIDS patients usually develop the condition of biliary abnormalities. Throughout this article, it was emphasized truthfully that this related pathology can be recognized by using MRCP modality. In addition, it was also mentioned that MRCP is a technique that is safe and non-invasive to best rule out AIDS cholangiopathy. 

5)   Opinion of the Article

     In my opinion, I believed that this article is very helpful in explaining AIDS cholangiopathy disease in total. First thing first, it had described briefly about the incidences of AIDS cholangio-pathy, in which it was evolved few years back. Next, this article has clarified two cases of the same disease using MRCP; final result demonstrated the same appearance to the images. Lastly, in  the discussion part was clearly delineated about the nature of AIDS cholangiopathy.

APPEARANCE OF PATHOLOGY ON RADIOGRAPHS/IMAGES 

Figure 1: In the first case; (a) MIP image shows smooth narrowing involving the distal part of CBD with upstream dilatation of the proximal duct (arrow). (b) SSFSE RARE MRCP image shows focal dilatations and strictures of intrahepatic biliary ducts. 

Figure 2: In the second case; (a) Axial HASTE MRI image reveals bulky papilla bulging into the duodenal lumen. (b) SSFSE RARE image shows narrowing of terminal CBD (arrow) and focal dilatations involving segmental biliary ducts.

ARTICLE REVIEW 2

Author's Name : Harshad Devarbhavi, Teena Sebastian, Sandeep M. Seetharamu and Dheeraj Karanth

Article Title : HIV/AIDS cholangiopathy: Clinical spectrum, cholangiographic features and outcome in 30 patients. 

Journal Name : Journal of Gastroenterology & Hepatology

1)   BIBLIOGRAPHY

Devarbhavi H., Sebastian T., Seetharamu S. M. & Karanth D. (2010). HIV/AIDS cholangiopathy: Clinical spectrum, cholangiographic features and outcome in 30 patients. Journal of Gastroenterology & Hepatology, 25(10): 1656–1660, doi:10.1111/j.1440-1746.2010.06336.x

2)  PURPOSE OF THE ARTICLE

The purpose of this article was to  describe the clinical profile and natural history of patients with

AIDS cholangiopathy and compare it with that reported in Western

literature and determine differences.

3)   BRIEF DESCRIPTION OF PROCEDURE AND FINDINGS/RESULTS

          Patients with HIV cholangiopathy underwent a detailed evaluation including risk factors, complete blood count, liver biochemical tests, HIV by ELISA, CD 4 counts, stool tests, urine tests, chest X-ray and ultrasonography of the abdomen, endoscopic retrograde cholangio-pancreatography (ERCP) or magnetic resonance cholangio-pancreatography (MRCP) or both. Ampullary biopsy was obtained (n-26) during ERCP and bile was aspirated (n-27) and sent for microbiological tests for Cryptosporidiosis, Microsporidia and Cyclospora. Past and present histories of opportunistic infections, treatment with anti-retroviral drugs, were noted. Follow up was available for all except three patients. Patients with abdominal pain and papillary stenosis underwent sphincterotomy. Sphincterotomy was not carried out in patients who had no pain or were asymptomatic. ERCP abnormalities or HIV cholangiopathies were classified into four types as previously described which include:

• Type 1: papillary tenosis
• Type 2: sclerosing cholangitis 
• Type 3: combined papillary stenosis and sclerosing cholangitis 
• Type 4: long extrahepatic strictures 

Sclerosing cholangitis was defined as bile duct dilatation with irregular margins either in the intrahepatic or extrahepatic ducts a picture similar to those seen in patients with primary sclerosing cholangitis.

          The findings shows that from Jan 1999 to May 2009, 30 patients (27 men) with AIDS cholangiopathy were seen. The most common mode of transmission was heterosexual (n = 28) followed by blood transfusion (n = 2). Abdominal pain (n = 20) of biliary origin, was the commonest manifestation followed by an asymptomatic group (n = 6) and a third group (n = 3) with pain due to pancreatitis. Ultrasonography of the abdomen was abnormal in all patients. Papillary stenosis (n = 23) was the most common cholangiographic feature followed by sclerosing cholangitis (n = 5). Abdominal pain resolved reliably and promptly after endoscopic sphincterotomy. Cholangiographic abnormalities regressed during follow up on antiretroviral therapy in 10 patients. Seven patients on anti retroviral therapy developed de novo cholangiopathy, with a precipitous drop in CD4 count of whom two had a worse prognosis. None had Kaposi’s sarcoma.

4)   CONCLUSIONS AND COMMENTS

The results from the investigation shows that, HIV cholangiopathy was seen predominantly in patients who acquired HIV by heterosexual transmission which is in contrast to Western literature. De novo development of cholangiopathy on antiretroviral therapy may indicate the occurrence of resistance. Papillary stenosis is the most common feature. Abdominal pain resolved with sphincterotomy. Regression of cholangiographic abnormality occurred with anti retroviral medications. Median survival following cholangiopathy diagnosis was 34 months, higher than reported in previous studies.

5)   OPINION OF THE ARTICLE

I thought this article provides very useful information regarding the AIDS cholangiopathy disease. The natural of the disease and patient's infected are also well described. Furthermore, it gives a better understanding of how AIDS cholangiopathy is diagnosed, what is affected and how it is treated.

APPEARANCE OF PATHOLOGY ON RADIOGRAPHS/IMAGES 

Figure 1: Ultrasonography demonstrates dilatation of common bile duct.

Figure 2: ERCP (endoscopic retrograde cholangio-pancreatography) showing 

massive dilatation of the common bile ducts and hepatic ducts 

secondary to papillary stenosis.

Figure 3: ERCP (endoscopic retrograde cholangio-pancreatography) demonstrating 

dilatation of the common bile duct and mild pancreatic duct 

dilatation secondary to papillary stenosis.

Figure 4: ERCP (endoscopic retrograde cholangio-pancreatography) demonstrates 

massive dilatation of common bile duct and pancreatic duct.

Figure 5: ERCP (endoscopic retrograde cholangio-pancreatography) demonstrating
irregularity of intrahepatic ducts and common bile duct suggestive of
sclerosing cholangitis with common bile duct dilatation.

Figure 6: ERCP (endoscopic retrograde cholangio-pancreatography) demonstrating
common hepatic duct stricture with massive upstream dilatation.

ARTICLE REVIEW 1

Name:

1. Dr. Leonardo Lidid A
2. Int Camilo Apey R

Article Title:

AIDS-associated cholangiopathy: When only the image is not enough

Journal Name:
Chilean Journal of Radiology

1)   Bibliography

Lidid L., & Apey C. (2012). AIDS-associated cholangiopathy: When only the image is not enough. Chilean Journal of Radiology, 18(4), 184-189. Retrieved from http://www.webcir.org/revistavirtual/articulos/marzo13/chile/ch_ingles.pdf

2)   Purpose of the Article

The article review some of the modalities used to diagnose the pathology, specifically the AIDS Cholangiopathy. The imaging studies play a vital diagnostic role providing relevant diagnostic information, hence it should be always evaluated according to patients clinical context. ERCP is known as a gold standard for diagnosis of AIDS cholangiopathy, usually researved to clearly exclude the presence of malignany, or as a specific invasive therapeutic procedure when indicated. Likewise, MRI and MRCP  are able to demonstrate parietal as well as stenotic biliary changes, while ultrasound and CT scans can provide relevant diagnostic information as well.  Hence the purpose of this article is to evaluate the findings based on the varoious modalities used to asses AIDS related cholagiopathy.

3)   Brief Description of Procedure and Findings/Results

This article describe a case report of a male patient, 21 y/o, who is HIV positive diagnosed at the age of 19 y/o. The patient also having a lack of adherence to antiretroviral therapy (ART) and gone for multiple treatments due to complications of the previous illness which include pneumonia, oropharyngeal candidiasis and a disseminated Kaposi sarcoma.  Recently, the patient was hospitalized and the result shows he is had a  right upper quadrant abnominal pain associated with jaundice and CEG. Three months prior to the ospitalization the CD4 T lymphocyte count was less than 20/mm³
.  

     Abdominal Ultrasonography revealed a  suspicious density within the spleen. Hepatosplenomegaly is described with diffusely thickened walls, without stones and an extrahepatic duct without dilatation, with marked parietal thicking. Tomographic test was performed and similar findings are observed. A biopsy was done and non-necrotising granulomas were discovered. Sarcoidosis was diagnosed after excluding other known causes of granulomatous disease. Further investigation was planned to further diagnose the progression. An abdominal MRI revealed a beaded pattern of the intrahepatic bile duct without inferior stones with other similar findings was observed. 

4)   Conclusions and Comments

At present, the combined use of magnetic resonance imaging and magnetic resonance cholangiopancreatography (MRCP) are very useful for evaluating both biliary and hepatic parenchymal diseases. In these can be seen, the same findings of thickening, edema and parietal biliary capture as described in CT, being able to add in the cholangiographic sequences morphological patterns similar to those described in ERCP. The noninvasive nature and good overall performance exhibited by MRCP in the evaluation of biliary disorders, including sclerosing cholangitis, means that some authors suggest their use for diagnostic ends, reserving ERCP for symptomatic treatment of CAS or for ruling out neoplasias using direct histological or cytological studies. Finally, there is a consensus that the definite diagnosis of CAS be achieved by proper interpretation of medical histories, laboratory findings and imaging patterns

5)   Opinion of the Article

The articles provide a very useful information regarding AIDS related cholagniopathy. The image provided with a good discussion clears the purposes of the article. Although the final result demonstrated the same appearance to the images in diagnosing the pathology, however the MRCP shows a very good diagnostic information as compared to Ultrasound and ERCP provided that it is also non-invasive as compared to ERCP.

APPEARANCE OF PATHOLOGY ON RADIOGRAPHS/IMAGES

Figure 1: Gallbladder and spleen involvement in AIDS-associated cholangiopathy. Ultrasound guidance.

a) Ultrasound image of the gallbladder with wall thickening (arrowheads). 

b) Longitudinal ultrasound cut shows normal caliber bile duct

(marked with the number 1) and an apparent hepatocholedochus wall thickening (indicated with the number 2).

Figure 2. Contrasted axial CT of the abdomen in AIDS-associated cholangiopathy. 

A) In portal phase evidence of parietal vesicular edema with mucosa impregnation of same (arrowheads). In the retroperitoneum an adenopathic conglomerate secondary to the disseminated Kaposi sarcoma begins to appear (arrows), which is much more evident at pelvic level (not shown). 

B) Thickening of the biliary parietal, with significant impregnation of contrast medium (arrowheads).

Figure 3. Abdominal MRI of AIDS-associated cholangiopathy.

image (a)

a) axial T2 sequence showing thickening and vesicular

parietal edema (arrowheads).

image (b)

b) Axial T1 FAT-SAT portal phase post gadolinium acquisition showing the same findings

and presence of obvious mucosal impregnation with contrast medium (arrow heads).

image (c)

c) Contrasted coronal T1 FAT-SAT

acquisition showing thickening and parietal impregnation of the common bile duct.

image (d)

image (e)

 image (f)

In (d) the already described vesicular edema (arrowheads) and the intrahepatic bile

duct alterations (beading) become evident, which are more visible in another orthogonal projection (e) in a focalized extension of the left biliary tree (arrowheads) of this same image (f).

EPIDEMIOLOGY OF THE DISEASE

The incidence and prevalence data of Cholangiopathy related to AIDS is still insufficient. Although in prehighly active antiretroviral theraphy (HAART) era , the prevalence of the disease was reported as 26 percent to 46 percent only (Naseer M et al.,2018). Moreover, before the introduction of HAART, there is approximately only 250 cases reported in the literature. This problem is largely lacking especially from developing country. Although the cases is rarely reported, AIDS cholangiopathy remains an important differential diagnosis for chilestatic liver disease in which it is attributable to resistance for the first line antiretroviral medications especially in HIV-infected patients (Braitstein P. et al., 2006; as cited by Naseer M, 2018). The author further explains that among the reasons for the lacking of information in developing country including poor access to HAART resources, non-adherence with treatment plans and medications and lack awareness about the disease.

INTRODUCTION

BACKGROUND OF THE STUDY

     AIDS cholangiopathy is a syndrome of biliary obstruction resulting from infection-related strictures of the biliary tract. It is considered as a rare disease reported mainly from the West, however due to HIV epidemic in india, the incidence could rises in the country. AIDS cholangiopathy occurred predominantly from a patients who acquired AIDS by heterosexual transmission prior to the advent of highly active antiretroviral therapy (Devarbhavi et. al, 2010). Although it has been reported that the incidence is decreasing in the era of potent antiretroviral therapy, but the source of incidence is still unclear (Chen et. al, 2002).

PROBLEM STATEMENTS 

HIV/AIDS patient may require special management in healthcare. Some of them might have claustrophobia which prevents them from undergo MRCP. Patient who is having an allergy to seafood might be suggested to go for US as the modalities not require any contrast media. ERCP is currently a gold standard for AIDS/HIV Cholangiopathy, however it is invasive, require the use of CM and costly. Hence, there is a need to choose appropriate modalities based on patient conditions and medical history.