Recurrent pyogenic cholangitis in a case with congenital biliary anomaly
Seyfettin Köklü*, Mehmet Ali Akkuş†, Adnan Taş‡,
, Zeliha Tufan§, Yusuf Tanrikulu||, Murat Kekilli¶, Erdem Koçak‡, Mehmet Alparslan Gönültaş**, Ömer Yimaz††
Corresponding author
* Associate professor, Department of Gastroenterology, Ankara Education and Research Hospital, Ankara, Turkey
† Professor, Department of Surgery, Ankara Education and Research Hospital, Ankara, Turkey
‡ Research Fellow, Department of Gastroenterology, Ankara Education and Research Hospital, Ankara, Turkey
§ Specialist, Department of Infectious Disease, Ankara Education and Research Hospital, Ankara, Turkey
|| Specialist, Department of Surgery, Ankara Education and Research Hospital, Ankara, Turkey
¶ Research Fellow, Department of Gastroenterology, Türkiye Yüksek Ihtisas Hospital, Ankara, Turkey
** Specialist, Department of Pathology, Ankara Education and Research Hospital, Ankara, Turkey
†† Specialist, Department of Radiology, Ankara Education and Research Hospital, Ankara, Turkey
Read
2201
Timeswas read the article
438
Total PDF
1763
Total HTML
Share statistics
array:24 [ "pii" => "S166526811931035X" "issn" => "16652681" "doi" => "10.1016/S1665-2681(19)31035-X" "estado" => "S300" "fechaPublicacion" => "2012-03-01" "aid" => "70791" "copyright" => "Fundación Clínica Médica Sur, A.C." "copyrightAnyo" => "2012" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Ann Hepatol. 2012;11:268-71" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 97 "formatos" => array:3 [ "EPUB" => 10 "HTML" => 60 "PDF" => 27 ] ] "itemSiguiente" => array:19 [ "pii" => "S1665268119310361" "issn" => "16652681" "doi" => "10.1016/S1665-2681(19)31036-1" "estado" => "S300" "fechaPublicacion" => "2012-03-01" "aid" => "70792" "copyright" => "Fundación Clínica Médica Sur, A.C." "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "nws" "cita" => "Ann Hepatol. 2012;11:272-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 64 "formatos" => array:3 [ "EPUB" => 8 "HTML" => 28 "PDF" => 28 ] ] "en" => array:8 [ "idiomaDefecto" => true "titulo" => "Cellular microRNA and the tumorigenesis of hepatocellular carcinoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "272" "paginaFinal" => "274" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Yu Li, Kris V. Kowdley" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Yu" "apellidos" => "Li" ] 1 => array:2 [ "nombre" => "Kris V." "apellidos" => "Kowdley" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119310361?idApp=UINPBA00004N" "url" => "/16652681/0000001100000002/v1_201906150950/S1665268119310361/v1_201906150950/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1665268119310348" "issn" => "16652681" "doi" => "10.1016/S1665-2681(19)31034-8" "estado" => "S300" "fechaPublicacion" => "2012-03-01" "aid" => "70790" "copyright" => "Fundación Clínica Médica Sur, A.C." "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Ann Hepatol. 2012;11:265-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 49 "formatos" => array:3 [ "EPUB" => 6 "HTML" => 12 "PDF" => 31 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Fulminant hepatitis during self-medication with conjugated linoleic acid" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "265" "paginaFinal" => "267" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 750 "Ancho" => 2074 "Tamanyo" => 346437 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Biopsy shows massive hepatic necrosis suggesting toxic liver damage.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rita Nortadas, José Barata" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Rita" "apellidos" => "Nortadas" ] 1 => array:2 [ "nombre" => "José" "apellidos" => "Barata" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119310348?idApp=UINPBA00004N" "url" => "/16652681/0000001100000002/v1_201906150950/S1665268119310348/v1_201906150950/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "titulo" => "Recurrent pyogenic cholangitis in a case with congenital biliary anomaly" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "268" "paginaFinal" => "271" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Seyfettin Köklü, Mehmet Ali Akkuş, Adnan Taş, Zeliha Tufan, Yusuf Tanrikulu, Murat Kekilli, Erdem Koçak, Mehmet Alparslan Gönültaş, Ömer Yimaz" "autores" => array:9 [ 0 => array:3 [ "nombre" => "Seyfettin" "apellidos" => "Köklü" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff1" ] ] ] 1 => array:3 [ "nombre" => "Mehmet" "apellidos" => "Ali Akkuş" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">†</span>" "identificador" => "aff2" ] ] ] 2 => array:4 [ "nombre" => "Adnan" "apellidos" => "Taş" "email" => array:1 [ 0 => "dradnantas@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">‡</span>" "identificador" => "aff3" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] 3 => array:3 [ "nombre" => "Zeliha" "apellidos" => "Tufan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">§</span>" "identificador" => "aff4" ] ] ] 4 => array:3 [ "nombre" => "Yusuf" "apellidos" => "Tanrikulu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">||</span>" "identificador" => "aff5" ] ] ] 5 => array:3 [ "nombre" => "Murat" "apellidos" => "Kekilli" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¶</span>" "identificador" => "aff6" ] ] ] 6 => array:3 [ "nombre" => "Erdem" "apellidos" => "Koçak" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">‡</span>" "identificador" => "aff3" ] ] ] 7 => array:3 [ "nombre" => "Mehmet" "apellidos" => "Alparslan Gönültaş" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "**" "identificador" => "aff7" ] ] ] 8 => array:3 [ "nombre" => "Ömer" "apellidos" => "Yimaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">††</span>" "identificador" => "aff8" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Associate professor, Department of Gastroenterology, Ankara Education and Research Hospital, Ankara, Turkey" "etiqueta" => "*" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Professor, Department of Surgery, Ankara Education and Research Hospital, Ankara, Turkey" "etiqueta" => "†" "identificador" => "aff2" ] 2 => array:3 [ "entidad" => "Research Fellow, Department of Gastroenterology, Ankara Education and Research Hospital, Ankara, Turkey" "etiqueta" => "‡" "identificador" => "aff3" ] 3 => array:3 [ "entidad" => "Specialist, Department of Infectious Disease, Ankara Education and Research Hospital, Ankara, Turkey" "etiqueta" => "§" "identificador" => "aff4" ] 4 => array:3 [ "entidad" => "Specialist, Department of Surgery, Ankara Education and Research Hospital, Ankara, Turkey" "etiqueta" => "||" "identificador" => "aff5" ] 5 => array:3 [ "entidad" => "Research Fellow, Department of Gastroenterology, Türkiye Yüksek Ihtisas Hospital, Ankara, Turkey" "etiqueta" => "¶" "identificador" => "aff6" ] 6 => array:3 [ "entidad" => "Specialist, Department of Pathology, Ankara Education and Research Hospital, Ankara, Turkey" "etiqueta" => "**" "identificador" => "aff7" ] 7 => array:3 [ "entidad" => "Specialist, Department of Radiology, Ankara Education and Research Hospital, Ankara, Turkey" "etiqueta" => "††" "identificador" => "aff8" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Correspondence and reprint request:" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0010" "etiqueta" => "<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 2</span></span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 753 "Ancho" => 1004 "Tamanyo" => 48516 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Endoscopic retrograde cholangiography demonstrating normal choleduct and right intra hepatic biliary tree.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Recurrent pyogenic cholangitis (RPC) is characterized by recurrent cholangitis attacks, dilated bile ducts and intrahepatic pigment stones.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Typically its prevalence is high either in natives or immigrants of South-east Asian population. Sporadic cases have been very rarely reported among natives of other parts of the world.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although the mechanism underlying the initiation of biliary sepsis is unknown, parasites including <span class="elsevierStyleItalic">Ascaris lumbricoides</span> and <span class="elsevierStyleItalic">Clonorchis sinensis</span>, enteric microorganisms, and malnutrition are accused as the triggering factors.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Stone formation is thought to result from the action of bacterial beta-glucuronidase on conjugated bilirubin. Although congenital biliary defects are usually of no clinical importance, occasionally these defects may lead to bile stasis, inflammation and biliary stones. Congenital biliary anomaly and RPC relationship has not been described before. Herein, we have reported for the first time RCP in a patient with congenital biliary anomaly. We have also discussed the diagnostic and therapeutic difficulties of that extremely rare association.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case Report</span><p id="p0010" class="elsevierStylePara elsevierViewall">A 43-years-old woman admitted with the complaint of fever for three days. Her past medical history revealed intermittent upper abdominal pain and fever for the last 2 years. She had admitted to other medical centers several times with the same complaints and laboratory tests including liver enzymes and bilirubin were detected as unremarkable. At admission, she looked miserable, had fever (40 °C), hypotension (80/50 mmHg) and tachycardia (119/min). There was mild pain on deep epigastric palpation. Laboratory examination showed leukocytosis (23,000/mm<span class="elsevierStyleSup">3</span>) and thrombocytopenia (52,000/mm<span class="elsevierStyleSup">3</span>). Other abnormal findings were as follows:</p><p id="p0015" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="li0005"><li class="elsevierStyleListItem" id="list0005"><span class="elsevierStyleLabel">•</span><p id="p0020" class="elsevierStylePara elsevierViewall">Erythrocyte sedimentation rate: 53 mm/h.</p></li><li class="elsevierStyleListItem" id="list0010"><span class="elsevierStyleLabel">•</span><p id="p0025" class="elsevierStylePara elsevierViewall">C-reactive protein: 32 (N: 0-0.8).</p></li><li class="elsevierStyleListItem" id="list0015"><span class="elsevierStyleLabel">•</span><p id="p0030" class="elsevierStylePara elsevierViewall">Blood urea nitrogen: 73 mg/dL.</p></li><li class="elsevierStyleListItem" id="list0020"><span class="elsevierStyleLabel">•</span><p id="p0035" class="elsevierStylePara elsevierViewall">Serum creatinine: 2.2 mg/dL.</p></li><li class="elsevierStyleListItem" id="list0025"><span class="elsevierStyleLabel">•</span><p id="p0040" class="elsevierStylePara elsevierViewall">Plasma albumin 3.2 g/dL.</p></li></ul></p><p id="p0045" class="elsevierStylePara elsevierViewall">Other blood tests including liver enzymes and bilirubin were all within normal limits. Chest X-ray was normal. Urine analysis was free of bacteria or leukocyte. Abdominal ultrasonography and tomography showed biliary dilatation at the left lobe of liver <a class="elsevierStyleCrossRef" href="#f0005">(Figure 1)</a>. Gallbladder and choleduct could not be differentiated due to marked dilated biliary tract. She was hospitalized and empirical intravenous antibiotic (ertapenem 1,000 mg/day) was initiated after taking blood and urine samples for bacterial culture.</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><p id="p0050" class="elsevierStylePara elsevierViewall">Endoscopic retrograde cholangiography (ERC) was performed showing normal choleduct and right intra hepatic biliary tree <a class="elsevierStyleCrossRef" href="#f0010">(Figure 2)</a>. Left intrahepatic biliary tree could not be visualized at ERC. Urine and blood cultures were non-diagnostic. Her clinical status and laboratory findings became better gradually and improved completely at the 5th day of hospitalization. Magnetic resonance cholangiopan-creatography (MRCP) demonstrated stone in the gallbladder, prominent dilatation of left biliary tree and stones in the left biliary ductules <a class="elsevierStyleCrossRef" href="#f0015">(Figure 3)</a>. Percutaneous cholangiopancreatography was performed showing marked biliary dilatation and numerous intrahepatic stones at the left lobe of the liver <a class="elsevierStyleCrossRef" href="#f0020">(Figure 4)</a>. Guide wire could not be passed through the choleduct because of hard stones. Surgery was planned and left hepatectomy was performed.</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><elsevierMultimedia ident="f0015"></elsevierMultimedia><elsevierMultimedia ident="f0020"></elsevierMultimedia><p id="p0055" class="elsevierStylePara elsevierViewall">Two hepatic lobes appeared completely different macroscopically <a class="elsevierStyleCrossRef" href="#f0025">(Figure 5)</a>. Numerous biliary black pigment stones were present in the resected lobe. Moreover, her left hepatic duct was not connecting with the right hepatic duct, was strictured, and was opening to the duodenum separately. Also left hepatic artery was originated from left gastric rather than common hepatic artery. Histological examination of resected liver revealed dilated biliary ductules containing numerous black stones and secondary sclerosing cholangitis <a class="elsevierStyleCrossRef" href="#f0030">(Figure 6)</a>. At the post-operative follow-up she had biliary leakage from the resected side of remaining liver. Nasobiliary draining catheter was inserted into that side and complete resolution was achieved at the 30th day after operation. She was free of symptoms at the 3 months follow-up period.</p><elsevierMultimedia ident="f0025"></elsevierMultimedia><elsevierMultimedia ident="f0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="p0060" class="elsevierStylePara elsevierViewall">The present case report is featured for several aspects. First, RPC has been extremely rarely reported in population other than Southeast Asia. Second, congenital extrahepatic anomaly may be a triggering factor for RPC in the present case. Finally, her liver enzymes and serum bilirubin levels remained normal since the beginning of symptoms and even during sepsis.</p><p id="p0065" class="elsevierStylePara elsevierViewall">RCP is a syndrome endemic to South-east Asia. Reports from the other parts are encountered mostly in Asian immigrants and sporadic cases have been reported among natives of other parts of the world.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0070" class="elsevierStylePara elsevierViewall">Right hepatic duct was the major conduit for the right and left lobes of liver. Typically, the left biliary ducts are affected most severely in the course of RPC. The pathogenesis of that left-side predominance is not known. Papilla of the sphincter of Oddi may be hypertrophied and fibrosed. Similarly left hepatic duct and its separate papilla were fibrosed and left hepatic duct was strictured in the present case.</p><p id="p0075" class="elsevierStylePara elsevierViewall">In our case although multiple stones were impacted in whole left lobe of the liver, there was no evidence of cholestatic findings based on the laboratory results. This may be ascribed to the presence of a communicating channel between the two extrahepatic bile ducts that provided another way for biliary excretion. Although MRCP has also played an important role in the diagnosis of double extrahepatic bile ducts, it did not provide detailed anatomical information about the biliary tree due to the multiple impacted stones in the current case.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>s</p><p id="p0080" class="elsevierStylePara elsevierViewall">The variations in the morphological characteristics of the extra-hepatic biliary system are rare and different types have been reported either alone or as in combinations in the literature. Complete duplication of the common bile duct occurs rarely.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The morphological classification of a double extrahepatic bile duct has been modified by Choi, <span class="elsevierStyleItalic">et al.</span><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Our case corresponded with a type IIIa anomaly according to that classification.</p><p id="p0085" class="elsevierStylePara elsevierViewall">Surgical management was the optimal option in the present case. She had a life-threatening septic attack, had stones within the intrahepatic ducts, and disease predominantly localized to the left hepatic ductal system. Although left hepatic lobectomy was curative, post-operative period was somehow problematic as a result of congenital variations in the present case. Surgery is also mandatory to prevent long-term complications including secondary biliary cirrhosis and cholangiocarcinoma in patients with RPC.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="p0090" class="elsevierStylePara elsevierViewall">In conclusion, RCP is a very rare disease in the world other than among cases living in South-east Asia. Recognition of RPC and underlying biliary variation is highly important in therapeutic management.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Disclosures</span><p id="p0095" class="elsevierStylePara elsevierViewall">We (all authors) declare that there is no conflict of interests among the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:3 [ "identificador" => "xres1207310" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1124356" "titulo" => "Key words" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Disclosures" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Key words" "identificador" => "xpalclavsec1124356" "palabras" => array:4 [ 0 => "Recurrent pyogenic cholangitis" 1 => "Congenital biliary anomaly" 2 => "Duplication of common biliary duct" 3 => "Hepatectomy" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abs0005" class="elsevierStyleSection elsevierViewall"><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Recurrent pyogenic cholangitis is endemic to South-east Asia but has been very rarely reported from natives of other parts of the world. A 43-years-old woman was presented with sepsis that had a history of recurrent epigastric pain and fever attacks. Her liver tests were unremarkable suggesting any hepatobiliary diseases. Recurrent pyogenic cholangitis and congenital extrahepatic biliary anomaly have been diagnosed after serial diagnostic and therapeutic procedures including endoscopic retrograde cholangiography, MR-cholangiography, percutaneous transhepatic cholangiography and finally left hepatectomy. She was cured completely following surgical treatment.</p></span>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "f0005" "etiqueta" => "<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 1</span></span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 904 "Ancho" => 1005 "Tamanyo" => 84543 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal computerized tomography showing prominent biliary dilatation at the left lobe of the liver.</p>" ] ] 1 => array:7 [ "identificador" => "f0010" "etiqueta" => "<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 2</span></span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 753 "Ancho" => 1004 "Tamanyo" => 48516 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Endoscopic retrograde cholangiography demonstrating normal choleduct and right intra hepatic biliary tree.</p>" ] ] 2 => array:7 [ "identificador" => "f0015" "etiqueta" => "<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 3</span></span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1004 "Ancho" => 1004 "Tamanyo" => 66955 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance cholangiopancreatography demonstrated stone in the gall bladder and prominent dilatation of left biliary tree.</p>" ] ] 3 => array:7 [ "identificador" => "f0020" "etiqueta" => "<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 4</span></span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 751 "Ancho" => 1000 "Tamanyo" => 58030 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Percutaneous cholangiopancreatography showing marked biliary dilatation and numerous intrahepatic stones at the left lobe of the liver.</p>" ] ] 4 => array:7 [ "identificador" => "f0025" "etiqueta" => "<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 5</span></span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 751 "Ancho" => 1000 "Tamanyo" => 154080 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Right lobe of the liver was normal whereas left hepatic lobe was shrunken and atrophied.</p>" ] ] 5 => array:7 [ "identificador" => "f0030" "etiqueta" => "<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 6</span></span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 751 "Ancho" => 1000 "Tamanyo" => 201720 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">Histological examination revealed dilated biliary ductules and inflamation (lymphocytic and neutrophilic).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recurrent pyogenic cholangitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Nguyen T." 1 => "Powell A." 2 => "Daugherty T." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10620-009-0912-3" "Revista" => array:6 [ "tituloSerie" => "Dig Dis Sci" "fecha" => "2010" "volumen" => "55" "paginaInicial" => "8" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19669879" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recurrent pyogenic cholangitis in a white woman" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Bergman S." 1 => "Di Carlo A." 2 => "Chaudhury P." 3 => "Blum C." 4 => "Nahal A." 5 => "Metrakos P." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Can J Surg" "fecha" => "2007" "volumen" => "50" "paginaInicial" => "E9" "paginaFinal" => "E10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18031628" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Parasitic infestations of the biliary tract" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Rana S.S." 1 => "Bhasin D.K." 2 => "Nanda M." 3 => "Singh K." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Curr Gastroenterol Rep" "fecha" => "2007" "volumen" => "9" "paginaInicial" => "156" "paginaFinal" => "164" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17418062" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intrahepatic lithiasis. Study of thirty-six cases and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Simi M." 1 => "Loriga P." 2 => "Basoli A." 3 => "Leardi S." 4 => "Speranza V." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "1979" "volumen" => "137" "paginaInicial" => "317" "paginaFinal" => "322" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/434323" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combined surgical and radiologic approach to recurrent cholangitis and intrahepatic pigment stones" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Reddy K.R." 1 => "Hutson D.G." 2 => "Russell E." 3 => "Jeffers L.J." 4 => "Schiff E.R." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "1988" "volumen" => "95" "paginaInicial" => "1383" "paginaFinal" => "1387" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3169501" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Duplication of the ex-trahepatic bile duct with anomalous union of the pancreaticobiliary ductal system revealed by MR cholangiopancreatography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Choi E." 1 => "Byun J.H." 2 => "Park B.J." 3 => "Lee M.G." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1259/bjr/50929809" "Revista" => array:6 [ "tituloSerie" => "Br J Radiol" "fecha" => "2007" "volumen" => "80" "paginaInicial" => "E150" "paginaFinal" => "E154" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17704313" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomical variations of the extrahepatic biliary tree: review of the world literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Lamah M." 1 => "Karanjia N.D." 2 => "Dickson G.H." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ca.1028" "Revista" => array:6 [ "tituloSerie" => "Clin Anat" "fecha" => "2001" "volumen" => "14" "paginaInicial" => "167" "paginaFinal" => "172" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11301462" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome of surgical treatment for recurrent pyogenic cholangitis: a single-centre study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Lee K.F." 1 => "Chong C.N." 2 => "Ng D." 3 => "Cheung Y.S." 4 => "Ng W." 5 => "Wong J." 6 => "Lai P." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "HPB (Oxford)" "fecha" => "2009" "volumen" => "11" "paginaInicial" => "75" "paginaFinal" => "80" "itemHostRev" => array:3 [ "pii" => "S0967586815002477" "estado" => "S300" "issn" => "09675868" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/16652681/0000001100000002/v1_201906150950/S166526811931035X/v1_201906150950/en/main.assets" "Apartado" => array:4 [ "identificador" => "77718" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/16652681/0000001100000002/v1_201906150950/S166526811931035X/v1_201906150950/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S166526811931035X?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 40 | 5 | 45 |
| 2024 September | 41 | 18 | 59 |
| 2024 August | 23 | 8 | 31 |
| 2024 July | 27 | 4 | 31 |
| 2024 June | 28 | 11 | 39 |
| 2024 May | 24 | 2 | 26 |
| 2024 April | 30 | 4 | 34 |
| 2024 March | 21 | 3 | 24 |
| 2024 February | 24 | 8 | 32 |
| 2024 January | 35 | 12 | 47 |
| 2023 December | 23 | 9 | 32 |
| 2023 November | 20 | 6 | 26 |
| 2023 October | 46 | 5 | 51 |
| 2023 September | 25 | 3 | 28 |
| 2023 August | 22 | 3 | 25 |
| 2023 July | 22 | 8 | 30 |
| 2023 June | 44 | 1 | 45 |
| 2023 May | 65 | 6 | 71 |
| 2023 April | 56 | 2 | 58 |
| 2023 March | 72 | 0 | 72 |
| 2023 February | 46 | 2 | 48 |
| 2023 January | 40 | 1 | 41 |
| 2022 December | 18 | 9 | 27 |
| 2022 November | 23 | 4 | 27 |
| 2022 October | 25 | 6 | 31 |
| 2022 September | 31 | 9 | 40 |
| 2022 August | 39 | 11 | 50 |
| 2022 July | 24 | 5 | 29 |
| 2022 June | 18 | 9 | 27 |
| 2022 May | 21 | 4 | 25 |
| 2022 April | 27 | 10 | 37 |
| 2022 March | 33 | 11 | 44 |
| 2022 February | 28 | 6 | 34 |
| 2022 January | 41 | 4 | 45 |
| 2021 December | 25 | 9 | 34 |
| 2021 November | 35 | 5 | 40 |
| 2021 October | 30 | 11 | 41 |
| 2021 September | 25 | 11 | 36 |
| 2021 August | 34 | 4 | 38 |
| 2021 July | 40 | 7 | 47 |
| 2021 June | 23 | 9 | 32 |
| 2021 May | 48 | 4 | 52 |
| 2021 April | 44 | 22 | 66 |
| 2021 March | 32 | 2 | 34 |
| 2021 February | 28 | 11 | 39 |
| 2021 January | 36 | 16 | 52 |
| 2020 December | 21 | 21 | 42 |
| 2020 November | 28 | 27 | 55 |
| 2020 October | 39 | 19 | 58 |
| 2020 September | 17 | 8 | 25 |
| 2020 August | 27 | 3 | 30 |
| 2020 July | 17 | 2 | 19 |
| 2020 June | 14 | 3 | 17 |
| 2020 May | 12 | 5 | 17 |
| 2020 April | 5 | 1 | 6 |
| 2020 March | 14 | 1 | 15 |
| 2020 February | 8 | 3 | 11 |
| 2020 January | 16 | 3 | 19 |
| 2019 December | 9 | 3 | 12 |
| 2019 November | 12 | 3 | 15 |
| 2019 October | 9 | 2 | 11 |
| 2019 September | 4 | 4 | 8 |
| 2019 August | 2 | 2 | 4 |
| 2019 July | 0 | 2 | 2 |
| 2019 June | 3 | 6 | 9 |
Show all
