A fungal mass in the urinary tract (fungus ball), mainly occurring in compromised patients, is a rare and dangerous complication of candiduria. We report 2 cases of fungus ball associated with hydronephrosis and sepsis. As reported in the literature, we treated the first patient by prompt relief of obstruction by nephrostomy and local and systemic antifungal agent. The second patient failed to respond to this treatment due to a distal ureteral stenosis and required open surgery with fungus ball removal and ureteral reimplantation. Despite a large success in urinary tract drainage with antifungal treatments, some cases need a modified approach due to anatomical modification.
Jaundice caused by intraluminal bile duct obstruction in infancy is rare but may occur in association with biliary sludge, inspissated bile plugs, or gall stones. Nine boys (aged 2 weeks-6 months) with obstruction caused by inspissated bile (n = 7) or gall stones (n = 2) are presented. Haemolysis was not a factor in the patients' histories but an abnormal entry of the common bile duct into the third part of the duodenum was demonstrated in two and one had an asymptomatic haemangioma. Ultrasonography was the most useful investigation. Surgical removal of the bile duct obstruction was necessary in eight cases and included biliary tract drainage in six and cholecystectomy for changes of cholecystitis in four. Obstruction resolved spontaneously in one infant after percutaneous cholangiography. There were no postoperative complications.
A case of isolated candidal fungal balls in the
common bile duct causing obstructive jaundice and
cholangitis is described. There were no predisposing
factors. The fungal balls were removed from the
common bile duct and a transduodenal sphincteroplasty
was performed. Microscopic analysis yielded
colonies of candida. Postoperative period was uneventful.
At follow-up no evidence of candida
infection was evident. He is now 3 years post-surgery
and is well.
Candida albicans is a fungus that can cause opportunistic urinary tract infections in immunocompromised patients. Disseminated fungaemia secondary to Candida albicans is associated with considerable mortality and therefore merits aggressive treatment. Diagnostic investigations for urosepsis and disseminated fungaemaia secondary to Candida albicans include positive urine and blood cultures. Herein, we describe an extremely unusual case of disseminated fungaemia associated with an obstructive fungus-ball in the distal ureter of an immunosuppressed patient. We also describe a novel application of an established endourological technique for managing this clinical scenario and discuss appropriate perioperative management strategies.
An immunocompetent 59-year-old man developed sinusitis over a 6- to 8-month period after cutting down a rotted maple tree (Acer sp.). A polypoid obstruction with a bloody drainage was evident in his right nasal cavity. A computed tomographic scan showed an opacification of the maxillary sinus. Surgery was performed to remove a fungus ball that had extended into the patient's medial sinus cavity. Sections of the sinonasal mucosa revealed marked acute and chronic sinusitis with inflammation, congestion, and hemorrhage. Sections from the pasty brown to black debrided material revealed a fungus ball consisting of an extensive network of brown-pigmented, septate, profusely branched hyphae. When grown on oat agar, the phaeoid fungus produced pycnidia and was identified as Pleurophomopsis lignicola. The genus Pleurophomopsis includes seven species, which are all known from plant material. This report documents for the first time a coelomycetous fungus, P. lignicola, causing sinusitis in an immunocompetent patient.
Secondary obstructive cholangiopathy is characterized by intra- or extrahepatic bile tract obstruction. Liver inflammation and structural alterations develop due to progressive bile stagnation. Most frequent etiologies are biliary atresia in children, and hepatolithiasis, postcholecystectomy bile duct injury, and biliary primary cirrhosis in adults, which causes chronic biliary cholangitis. Bile ectasia predisposes to multiple pathogens: viral infections in biliary atresia; Gram-positive and/or Gram-negative bacteria cholangitis found in hepatolithiasis and postcholecystectomy bile duct injury. Transmembrane toll-like receptors (TLRs) are activated by virus, bacteria, fungi, and parasite stimuli. Even though TLR-2 and TLR-4 are the most studied receptors related to liver infectious diseases, other TLRs play an important role in response to microorganism damage. Acquired immune response is not vertically transmitted and reflects the infectious diseases history of individuals; in contrast, innate immunity is based on antigen recognition by specific receptors designated as pattern recognition receptors and is transmitted vertically through the germ cells. Understanding the mechanisms for bile duct inflammation is essential for the future development of therapeutic alternatives in order to avoid immune-mediated destruction on secondary obstructive cholangiopathy. The role of TLRs in biliary atresia, hepatolithiasis, bile duct injury, and primary biliary cirrhosis is described in this paper.
A necrotic lung ball is a rare radiological feature that is sometimes seen in cases of pulmonary aspergillosis. This paper reports a rare occurrence of a necrotic lung ball in a young male caused by Candida and Streptococcus pneumoniae.
A 28-year-old male with pulmonary candidiasis was found to have a lung ball on computed tomography (CT) of the chest. The patient was treated with β-lactams and itraconazole and then fluconazole, which improved his condition (as found on a following chest CT scan) and serum β-D-glucan level. The necrotic lung ball was suspected to have been caused by coinfection with Candida and S. pneumoniae.
A necrotic lung ball can result from infection by Candida and/or S. pneumoniae, indicating that physicians should be aware that patients may still have a fungal infection of the lungs that could result in a lung ball, even when they do not have either Aspergillus antibodies or antigens.
lung ball; necrotic lung ball; Candida; Streptococcus pneumoniae
We describe the very unusual case of a patient with a large, free-floating left-atrial thrombus secondary to severe mitral stenosis, in whom the peculiar symptoms and complications of a ball thrombus were absent. The patient's only symptom before the episode reported here was mild dyspnea, which was attributed to mitral stenosis. She experienced neither embolism nor syncope. While even her clinical signs did not indicate a left-atrial ball thrombus, both echocardiography and angiography showed a free-floating thrombus. Because of the risk of stroke and acute obstruction of the mitral valve, emergency surgery was performed upon diagnosis of the ball thrombus. The surgery, which consisted of removing the thrombus and replacing the mitral valve with a mechanical prosthesis, was uneventful. A computed tomographic brain scan prior to discharge did not detect any cerebral infarction.
Curative resection is the only treatment for biliary tract cancer that achieves long-term survival. However, patients with advanced biliary tract cancer have only a limited prognosis even after radical surgical resection. Thus, to improve the longterm results, the early detection of biliary tract cancer and subsequent cure seem to be essential. The purpose of this study was to review the literature concerning the risk factors for cancerous and precancerous lesions of the biliary tract, and prophylactic surgery for these factors. It has been reported that pancreaticobiliary maljunction (PBM) with bile duct dilatation is a risk factor for gallbladder cancer and bile duct cancer, while PBM without bile duct dilatation is a risk factor for gallbladder cancer. Thus, in the former group, a prophylactic excision of the common bile duct and gallbladder should be recommended, while in the later group, a prophylactic cholecystectomy without bile duct resection may be the appropriate surgical procedure. It has also been reported that primary sclerosing cholangitis (PSC) is a risk factor for cholangiocarcinoma. Patients with PSC often develop advanced cholangiocarcinoma with a poor prognosis. In patients with PSC, therefore, strict follow-up should be recommended. Adenoma and dysplasia have been regarded as precancerous lesions of gallbladder cancer. A polypoid lesion of the gallbladder that is sessile, has a diameter greater than 10 mm, and /or grows rapidly, is highly likely to be cancerous and should be resected. Although gallstones seem to be closely associated with gallbladder cancer, there is no evidence of a direct causal relationship between gallstones and gallbladder cancer. Thus, a cholecystectomy is not advised for asymptomatic cholecystolithiasis. Controversy remains as to whether adenomyomatosis of the gallbladder and porcelain gallbladder are associated with gallbladder cancer. With respect to ampullary carcinoma, adenoma of the ampulla is considered to be a precancerous lesion. This article discusses the risk factors for cancerous and precancerous lesions of the biliary tract and prophylactic treatment for these factors.
Biliary tract neoplasms; Risk factors; Prophylaxis therapy; Gallstones; Pancreaticobiliary maljunction; Precancerous conditions; Gallbladder; Guidelines
Gallbladder carcinosarcoma is one of the rarest subsets of gallbladder malignancies. The first case of carcinosarcoma of the gallbladder was reported in 1907. To date, <100 cases have been reported in the English literature. The present study reports a case of gallbladder carcinosarcoma accompanied with tumor thrombi, presenting as a soft tissue mass in the common bile duct and resulting in the obstruction and inflammation of the biliary tract. Initially, the patient was diagnosed with a gallbladder tumor and choledocholithiasis. No cases of carcinosarcoma of the gallbladder accompanied with bile duct tumor thrombus formation have been reported to date. A cholecystectomy with liver segmentectomy (S4a+S5) and a lymph node dissection were performed. The presence of a tumor thrombus in the common bile duct was confirmed by analysis of a frozen section during surgery. Resection of the extrahepatic bile duct and Roux-en-Y type hepatic cholangiojejunostomy were also performed. In addition, the gallbladder carcinosarcoma was observed to produce α-fetoprotein. The patient underwent an uneventful post-operative recovery and, to date, no clinical or radiological evidence of disease recurrence or metastasis has been identified. Carcinosarcoma of the gallbladder accompanied with tumor thrombi is extremely rare. Tumor thrombi in the common bile duct may easily be misdiagnosed as choledocholithiasis. The treatment and prognosis of gallbladder carcinosarcoma is similar to that of gallbladder carcinoma.
carcinosarcoma; gallbladder; tumor thrombi
The formation of bile duct bezoars is a rare event. Its occurrence when there is no history of choledochoenteric anastomosis or duodenal diverticulum constitutes an extremely scarce finding.
We present a case of obstructive jaundice, caused by the concretion of enteric material (bezoars) in the common bile duct following choledochoduodenal fistula development. Six years after cholecystectomy, a 60-year-old female presented with abdominal pain and jaundice. Endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects in her biliary tract. The size of the obstructing objects necessitated surgical retrieval of the stones. A histological assessment of the objects revealed fibrinoid materials with some cellular debris. Post-operative T-tube cholangiography (9 days after the operation) illustrated an open bile duct without any filling defects. Surprisingly, a relatively long choledochoduodenal fistula was detected. The fistula formation was assumed to have led to the development of the bile duct bezoar.
Bezoar formation within the bile duct should be taken into consideration as a differential diagnosis, which can alter treatment modalities from surgery to less invasive methods such as more intra-ERCP efforts. Suspicions of the presence of bezoars are strengthened by the detection of a biliary enteric fistula through endoscopic retrograde cholangiopancreatography. Furthermore, patients at a higher risk of fistula formation should undergo a thorough ERCP in case there is a biliodigestive fistula having developed spontaneously.
We report a rare case of granulocytic sarcoma infiltrating the bile duct in a patient with acute myeloid leukemia. A 23-year-old man presented with jaundice and weight loss. A peripheral blood smear revealed blast cells, and the results of an examination of bone marrow aspirate were consistent with acute myeloid leukemia. The bilirubin level increased gradually after induction chemotherapy with cytarabine. Magnetic resonance cholangiopancreatography (MRCP) revealed dilatation of the intrahepatic bile ducts and smooth tapering off at the level of the common hepatic bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) also revealed diffuse narrowing of the proximal common hepatic bile duct. Obstructive jaundice resolved after endoscopic nasobiliary drainage. Remission induction chemotherapy with cytarabine and idarubicin was administered, and the patient remained complete hematological remission with normal liver function tests.
Leukemia, Myelocytic, Acute; Jaundice, Obstructive; Bile ducts; Retrograde cholangiopancreatography, Endoscopic
The biliary excretion of imipenem-cilastatin studied by endoscopic cannulation of the common bile duct in patients with complete obstruction and in a group without obstruction showed that despite a 24-h prophylaxis, the bile obtained from patients with obstruction immediately after cannulation contained neither imipenem nor cilastatin, while there were 2 and 5% of peak concentrations in serum for imipenem and cilastatin, respectively, in the bile from patients without obstruction. Biliary excretion of both compounds increased rapidly after decompression, reaching a maximum of 15% of peak levels in serum within 2 h. Twenty-four hours after drainage, the biliary excretion of the drugs further improved. We conclude that since biliary obstruction impairs excretion of antibiotics, drainage is necessary for the control of sepsis in obstructed cholangitis.
The most common abnormality of the lacrimal drainage system is congenital or acquired nasolacrimal duct obstruction. The causes of acquired nasolacrimal duct obstruction may be primary or secondary. The secondary acquired obstructions may result from infection, inflammation, neoplasm, trauma or mechanical causes. The maxillary sinus cysts usually obstruct the nasolacrimal duct mechanically. Dentigerous cysts are one of the main types of maxillary cysts. These cysts are benign odontogenic cysts which are associated with the crowns of unerupted teeth. The clinical documentations of mechanical nasolacrimal duct obstructions due to a dentigerous cyst in the maxillary sinus are very rare in literature. In this case report, we describe a dentigerous cyst with a supernumerary tooth in the maxillary sinus in an 11-year-old male child causing an obstruction to the nasolacrimal duct. The case was successfully managed surgically by Caldwell Luc approach.
Caldwell Luc approach; dentigerous cyst; nasolacrimal duct
Ampicillin levels were measured in the serum and in the bile from both the gall bladder and the common bile duct in patients undergoing surgery for biliary tract diseases. In patients with radiologically non-functioning gall bladders ampicillin was either not present or its concentration was lower than normal. Therapeutic levels were present in the common bile duct of all patients except those with obstruction of the common bile duct. Hence ampicillin fails appreciably to penetrate the obstructed viscus in obstructive biliary tract disease, and it is unlikely to be effective in treating infection associated with this.
Isolated frontal sinusitis with mixed bacterial colonies is extremely rare and has not been described. We report a case of isolated frontal sinus forming mixed bacterial colonies that occurred in the previously exposed frontal sinus. The material in the frontal sinus was macroscopically similar to sinus fungus ball. Surgical strategy followed that for sinus fungus ball. The material could not be completely removed even with an endoscopic modified Lothrop procedure (Draf type III procedure). Additional external incision enabled complete removal of the remnant infectious substance. Histological examination detected two different types of organisms as intermingled bacterial colonies. External approaches to the frontal fungus ball have recently been replaced by the endonasal approach. Our case suggests that material trapped in a pit or small crevice in a frontal sinus may not be removed intranasally.
We encountered 10 patients with bile duct injuries during laparoscopic cholecystectomy.
Their causes were electrocautery in 2 patients, misjudgment in 2, mechanical injury in 3,
aberrant bile duct in 2, and weakness of the bile duct wall in one. The sites of injury were
cystic duct in 4 patients, common bile duct in 2, aberrant bile duct in 2, common hepatic
duct in one, and common bile duct plus right hepatic duct in one. Treatments for the injuries
discovered intraoperatively consisted of T-tube drainage above in 2 patients, re-ligation of
the cystic duct in one, ligation of an aberrant bile duct in one, simple suture and T-tube in
one, and choledochojejunostomy in one. In the remaining 4 patients discovered postoperatively,
2 were conservatively treated by endoscopic retrograde biliary drainage. The duration
of hospitalization was 9–12 days in the 4 patients with simple suture or ligation, 10–21
days in 2 cases of bile drainage, and 34–43 days in 3 with T-tube drainage. The patient with
choledochojejunostomy suffered repeated cholangitis, resulting in hepatic abscess with
hospitalization for 6 months. Since laparoscopic surgery should be minimally invasive,
meticulous attention is necessary before and during surgery to avoid bile duct injury.
The biliary tract excretion of three cephalosporins, cefazolin, cephaloridine, and cephalothin, was compared in patients with biliary tract disease. In the absence of obstruction, mean antibiotic levels in bile from gall bladder and common duct in patients undergoing cholecystectomy were highest for cefazolin (17 and 31 μg/ml, respectively) than either cephaloridine (7 and 9 μg/ml) or cephalothin (1 and 4 μg/ml). Biliary tract levels generally paralleled serum levels. In no patient with cystic duct obstruction were any of the cephalosporins detectable in appreciable amounts in gall bladder bile. In patients with T-tube drainage given each of the three different cephalosporins on separate days, concentrations of cefazolin in bile were many-fold higher than either cephaloridine or cephalothin. Peak levels of cefazolin in T-tube bile averaged 51 μg/ml after intravenous and 26 μg/ml after intramuscular administration, whereas mean peak levels of cephalothin and cephaloridine were only 6 and 16 μg/ml, respectively. Here, too, T-tube levels reflected serum concentrations and obstruction to biliary flow impaired excretion of each of the drugs.
The intrahepatic biliary tree can occasionally be infected by Mycobacteriurn tuberculosis, but tuberculosis of the common bile duct has not previously been reported. A 38-year-old man with obstructive jaundice, who was originally thought to have cholangiocarcinoma associated with opisthorchiasis (a common combination in Thailand), was finally proved to have tuberculosis of the common bile duct with adjacent tuberculous lymphadenitis. Following T-tube drainage and antitubercular therapy, he made a complete recovery. The importance of a tissue diagnosis in all cases of obstructive jaundice is emphasized to avoid missing rare but curable diseases.
Endoscopic retrograde cholangio-pancreatography is the most appropriate technique for treating common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Even if the procedure is performed by skillful endoscopist, there are patients in whom endoscopic stent placement is not possible. Common causes of failure include complex peri-papillary diverticula, prior surgery procedures, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones. Percutaneous trans-hepatic biliary drainage (PTBD) and surgical intervention carry morbidity and mortality. Recently endoscopic ultrasonography-guided biliary drainage has been reported as an alternative technique. Endoscopic ultrasonography-guided biliary drainage using either direct access or a rendezvous technique has attracted attention as an alternative procedure to PTBD, with a technical success between 75%-100% and with low complication rate. We have reviewed published data on EUS guided biliary drainage procedures with the aim of summarizing the efficacy and safety of this promising method.
Interventional endoscopic ultrasonography; Endoscopic ultrasonography drainage; Biliary drainage; Endoscopic retrograde cholangio-pancreatography
Spontaneous biliary tract fistulas are rare entities. Most of them are associated with long-standing gallstones (especially common bile duct stones, or recurrent biliary tract infections), some with more uncommon diseases such as gallbladder cancer. Some authors believe that back flow from fistulas predisposes patients to gallbladder cancer and some believe that cancer causes necrosis and fistula formation. Gallbladder cancer has a dismal prognosis and 85% of patients are dead within a year of diagnosis. A common complication of gallbladder cancer is obstruction of the common bile duct, which may produce multiple intra-hepatic abscesses in or near the tumor-laden gallbladder. Fistula formation may further complicate the clinical picture.
We present a case of choledochoduodenal fistula in a 60-year-old diabetic African-American woman with gallbladder cancer. The initial clinical presentation was confusing and complex. Our patient was also found to have a gallbladder fossa abscess that was drained percutaneously as another complicating factor relating to her cancer. She developed myocardial infarction, massive upper gastrointestinal bleeding and respiratory arrest during her stay in hospital. Computed tomography was very helpful in assessing our patient and we discuss how, in a patient with pneumobilia, it can be helpful for detecting fistula, air in bile ducts or to show contractions of the gallbladder.
We believe this case merits reporting as it shows an entity that is not frequently thought of, is hard to diagnose and can be fatal, as in our patient. Careful evaluation, and computed tomography studies and endoscopic retrograde cholangio-pancreatography are helpful in early diagnosis and finding better management options for these patients.
Jaundice presenting after cholecystectomy may be the initial manifestation of a serious surgical misadventure and requires rigorous diagnostic pursuit and therapeutic intervention. Biloma is a well recognized postcholecystectomy complication that often accompanies biliary ductal injury.
A 23-year-old female underwent laparoscopic cholecystectomy for symptomatic gallstones and three weeks postoperatively developed painless jaundice. Radiographic and endoscopic studies revealed a subhepatic biloma causing extrinsic compression and obstruction of the common hepatic duct.
Percutaneous catheter drainage of the biloma combined with endoscopic sphincterotomy successfully relieved the extrahepatic biliary obstruction and resolved the intrahepatic ductal leak responsible for the biloma.
Although heretofore undescribed, post-cholecystectomy jaundice due to extrahepatic bile duct obstruction caused by biloma may occur and can be successfully treated by means of standard radiologic and endoscopic interventions.
Cholecystectomy; Biloma; Biliary obstruction; Interventional radiology
The pharmacokinetics of ciprofloxacin excretion have been studied in 54 patients undergoing biliary and
pancreatic operations with and without obstruction of the common bile duct. High concentrations were
achieved in common duct bile within 20 minutes of intravenous injection and persisted for over 3 hours
after 100 mg and for over 8 hours after 200 mg. The concentration of ciprofloxacin in the bile of functioning
gall bladders was much greater than that in the common duct bile. Remarkably, it was identified in
therapeutic concentrations in the bile of obstructed ducts. This and the rapid fall from initially high venous
concentrations probably reflect diffusion from the circulation as a result of the exceptional tissue
penetration. A unique feature of this study was the finding of clinically significant concentrations in the
bile of obstructed ducts.
Two patients developed wound infection and no side effects were observed. The broad spectrum
antibiotic ciprofloxacin has potential as a useful agent for prophylaxis in biliary surgery maintaining biliary
and venous concentrations in excess of the MIC90 for most biliary pathogens for more than 8 hours.
Biliary stones are usually found in the gallbladder, but about 10-20% may spontaneously migrate into the common bile duct where they either remain trapped or migrate subsequently via the papilla of Vater into the duodenal lumen. In some cases, biliary stones may form de novo in the common bile duct because of local precipitating factors. We here present a spectacular case of huge gallstones impacted in the common bile duct (empierrement of the common bile duct) that led to the development of acute cholangitis with septic shock. Urgent nocturnal percutaneous cholangiography permitted biliary drainage and resolution of the cholangitis while the stones were secondarily removed surgically because of the large size of the stones.
Acute suppurative cholangitis may be fatal unless adequate biliary drainage is obtained in a timely manner. The association of fever and rapid onset of jaundice in elderly patients should always make physicians think of cholangitis.
A variety of evidence is presented, all of which supports the view that in the uninfected animal the intestinal tract is the only place of origin of urobilin, not merely under normal circumstances, but when there is biliary obstruction. Animals rendered urobilin-free by collection of all of the bile from the intubated common duct remain urobilin-free even after severe hepatic injury. In our experiments urobilinuria was never found after liver damage except when bile pigment was present in the intestine. Thus, for example, it appeared during the first days after Ugation of the common duct, but disappeared as the stools became acholic. When this had happened a small amount of urobilin-free bile, given by mouth, precipitated a prompt urobilinuria. After obstruction of the duct from one-third of the liver, mild urobilinuria was found, but no bilirubinuria. In animals intubated for the collection of a part of the bile only, while the rest flowed to the duodenum through the ordinary channels, liver injury caused urobilinuria, unless indeed it was so severe as to lead to bile suppression, when almost at once the urobilinuria ceased, though the organism became jaundiced. The evidence here presented, when taken with that of our previous papers, clearly proves that urobilinuria is an expression of the inability of the liver cells to remove from circulation the urobilin brought by the portal stream, with result that the pigment passes on to kidney and urine. Urobilinuria occurs with a far less degree of liver injury than does bilirubinuria. Our work has, for the most part, been carried out with animals having uninfected livers and bile passages. But the influence of cholangitis with infection has been briefly discussed in the light of some preliminary observations. The influence of infection on the place of formation of urobilin and on the occurrence of urobilinuria will form the subject of another communication.