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.

PROPOSED TITLE

Title: HIV/AIDS Cholangiopathy.

Definition: AIDS cholangiopathy is a syndrome of biliary obstruction resulting from
infection-related strictures of the biliary tract. AIDS cholangiopathy occurred in as many
as 26 percent of AIDS patients prior to the advent of highly active antiretroviral therapy;
the current incidence of cholangiopathy is not known, but has decreased in the era of potent
antiretroviral therapy.

Importance: 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.

Objectives:

1.   To determine the best modalities to diagnose the pathology.

2.   To compare the modalities in terms of cost effectiveness and image quality.

List of modalities:

1.   ERCP

2.   Ultrasound

3.   MRCP

Group members:

1.      Muhamad Ilhami Bin Mohd Ali Hanafiah (1517217)

2.      Nur Farah Hani Binti Muhammad Jaafar (1519976)