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).