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Objective The objective of the study was to evaluate the use of the hepatospecific contrast agent, gadoxetic acid, for MRI in patients at a high-complexity hospital in Medellin, Colombia, from 2016 to 2022. Materials and methods This was an observational, descriptive, and retrospective cross-sectional study involving patients who had undergone MRI with gadoxetic acid from February 2016 to January 2022. The MRI studies were interpreted by two radiologists specializing in body imaging, each with at least 10 years of experience. The medical records of the identified patients were reviewed. Quantitative variables were presented using either means and standard deviations or medians and interquartile ranges, depending on the distribution of the variables. Qualitative variables were represented through absolute and relative frequencies. Results A total of 100 pharmacy records were collected, leading to a final sample of 75 patients aged between three and 91 years. The primary reason for imaging was to assess focal liver lesions in 58 patients (77.3%), with bile duct injury being the second most common indication in 16 patients (21.3%). A diagnostic alteration was noted in 69.3% of cases (52 patients). Among the 58 focal liver lesions analyzed using a hepatospecific agent, 31 cases (53.4%) were diagnosed as focal nodular hyperplasia. Conclusion Our study reinforces the clinical value of gadoxetic acid-enhanced MRI in refining diagnostic assessments, particularly in cases involving bile duct and focal hepatic lesions.

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Radiological studies play a crucial role in the evaluation of patients with biliary duct obstruction, allowing for the guidance of clinical diagnosis towards a malignant or stone-induced etiology through the recognition of relevant imaging features, which must be continuously revisited given their prognostic significance. This article aims to emphasize the importance of recognizing crucial imaging aspects of malignant and stone-induced biliary obstruction.

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Introducción: La panlitiasis se define como la presencia de múltiples cálculos en el trayecto de la vía biliar. El manejo consiste en realizar una colangiopancreatografía retrógrada endoscópica (CPRE), la exploración de la vía biliar o la anastomosis biliodigestiva (ABD), ya sea coledocoduodenoanastomosis o hepaticoyeyunoanastomosis.Objetivo: Describir el caso clínico de un paciente con panlitiasis biliar, abordando la presentación clínica, los métodos diagnósticos, el tratamiento y la evolución, con el propósito de ofrecer un recurso sólido a la comunidad médica.Presentación del caso: Se presenta un paciente de 60 años colecistectomizado hace 13 años portador de anastomosis bilioentérica con panlitiasis recidivante, se realizó un lavado de la vía biliar con salida de cálculos y pus del interior, finalmente se colocó una sonda Kehr junto con tratamiento clínico. Presentó una evolución favorable. Discusión: Este caso reveló una panlitiasis a la exploración de las vías biliares bajo visión endoscópica, a pesar de que no se encontró obstrucción, el paciente tenía antecedente de colecistectomía y contaba con una derivación hepático-yeyunal por lesión iatrogénica. La decisión del tratamiento debe ser multidisciplinaria ya que cada caso es único y dependerá de las características del paciente y las condiciones clínicas individuales.Conclusiones: La panlitiasis coledociana recidivante requirió un control farmacológico estricto para evitar recurrencia y la subsecuente exploración de la vía biliar que incrementa la morbimortalidad del paciente. Es importante el seguimiento médico continuo del paciente y la predisposición con la que cuenta para la formación de litos, pudiendo ser prevenidos, identificados y tratados de manera oportuna

Introduction: Panlithiasis is define as the presence of multiple stones in the biliary tract that is classified as primary, secondary, or mixed according to the origin of the stones. Management consists of endoscopic retrograde cholangiopancreatography (ERCP), exploration of the biliary tract, or biliodigestive anastomosis (BDA), either choledochoduodenostomy or hepaticojejunostomy. Objective: Describe the clinical case of a patient with biliary panlithiasis, addressing the cli-nical presentation, diagnostic methods, treatment and evolution, with the purpose of offering a solid resource to the medical community.Case Presentation: We present a 60-year-old male patient who underwent cholecystectomy 13 years ago and has a bilioenteric anastomosis with recurrent panlithiasis. Biliary lavage was performed with the output of stones and pus from the inside. Finally, a Kehr tube was placed along with clinical treatment. The patient showed a favorable outcome.Discussion: This case revealed a panlithiasis upon exploration of the biliary tract under endoscopic vision. Despite finding no obstruction, the patient had a history of cholecystectomy and a hepatic-jejunal diversion due to iatrogenic injury. The treatment decision should be multidisciplinary, as each case is unique and depends on the patient's characteristics and individual clinical conditions.Conclusions: Recurrent choledocholithiasis required strict pharmacological control to prevent recurrence and subsequent exploration of the biliary tract, which increases patient morbidity and mortality. Continuous medical follow-up of the patient and the predisposition with which they have for the formation of stones is important. These can be prevented, identified, and treated in a timely manner.

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BACKGROUND: Von Meyenburg complexes are benign hamartomatous lesions, they are part of the spectrum of ductal plate malformations. They are rare, reported in 0.35-5.6% of the general population, predominantly in adults, with no clear predilection for sex. OBJECTIVE: To present the clinical characteristics of Von Meyenburg complexes in our region. METHOD: We searched all cases with diagnosis of Von Meyenburg complexes in a period from 2012 to 2022, in our institutions. RESULTS: We identified eight cases, with an average age of 59.25 years, with a predominance of females and with one case associated with gastric carcinoma. CONCLUSIONS: It is important to adequately recognize this entity, since due to its multifocal nature it can easily simulate metastasis, additionally, and its presence does not rule out other synchronous neoplasms.

ANTECEDENTES: Los complejos de Von Meyenburg son lesiones hamartomatosas benignas que forman parte del espectro de las malformaciones de la placa ductal. Son poco frecuentes, se reportan en un 0.35-5.6% de la población general, predominantemente en adultos, sin clara predilección por un sexo. OBJETIVO: Presentar las características clínicas de los complejos de Von Meyenburg en nuestro medio. MÉTODO: Se buscaron todos los casos con diagnóstico de complejos de Von Meyenburg en nuestras instituciones entre 2012 y 2022. RESULTADOS: Identificamos ocho casos, con un promedio de edad de 59.25 años, con predominio por el sexo femenino y con un caso asociado a carcinoma gástrico. CONCLUSIONES: Es importante reconocer y diagnosticar adecuadamente esta afección, ya que por su naturaleza multifocal fácilmente puede simular metástasis, y además su presencia no descarta otros procesos neoplásicos sincrónicos.

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The obstruction of the bile duct secondary to non-Hodgkin lymphoma is extremely rare. That's why we present the case of a 63-year-old female patient who sought medical attention due to jaundice, dark urine, acholia, and weakness. Laboratory results showed a cholestatic pattern, and an ultrasound revealed dilation of the intra and extrahepatic bile ducts, for which a cholangio resonance was ordered. It showed an expansive formation with ill-defined borders compromising the common hepatic duct associated with its stenosis. The initial suspicion was a Klatskin tumor, for which a biopsy was performed, which reported infiltration of a double expressor large B-cell lymphoma as a primary neoplasm of the bile duct. The patient underwent chemotherapy treatment with R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) and went into remission. Due to continuous episodes of cholangitis, a Roux-en-Y hepatic jejunal anastomosis with biliary tract reconstruction was performed. Currently, she remains in remission, seven years after the diagnosis. This case highlights the rarity of large B-cell non-Hodgkin lymphoma in the bile duct and emphasizes the importance of biopsy for effective treatment, combining chemotherapy for the underlying disease and surgery for obstructive complications.

La obstrucción de la vía biliar secundaria a un linfoma no hodgkin es extremadamente raro. Es por esto que presentamos el caso de una paciente femenina de 63 años que consulta por ictericia, coluria, acolia y astenia. Un laboratorio presentando un patrón colestásico y una ecografía con la vía biliar intra y extrahepática dilatadas llevaron a realizar una colangioresonancia de abdomen que evidenció una formación expansiva de limites mal definidos que comprometía el conducto hepático común asociado a estenosis del mismo. La sospecha inicial fue un tumor de klatskin y se llevó a cabo la toma de biopsia, cuyo resultado anatomopatológico informó infiltración de linfoma de células B de células grandes doble expresor como tumor primario de la vía biliar. Realizó tratamiento quimioterápico con esquema R CHOP (rituximab, ciclofosfamida, doxorrubicina, vincristina, prednisona) y entró en remisión. Por continuos episodios de colangitis se optó por realizar una hepático yeyuno anastomosis en Y de Roux con reconstrucción de la vía biliar. Actualmente continúa en remisión a 7 años del diagnóstico. El caso resalta la rareza del linfoma no hodgkin de células B grandes en la vía biliar, y destaca la importancia de la biopsia para un tratamiento eficaz que combina la quimioterapia para la enfermedad de base y la cirugía para las complicaciones obstructivas.

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ABSTRACT Intrahepatic biliary proliferations represent a spectrum from reactive (ductular reaction, some with atypical architecture), hamartomatous (von Meyenburg complex), benign (bile duct adenoma) and precursor/borderline entities (biliary intraepithelial neoplasia, intraductal papillary neoplasm of the bile duct) to fully malignant (cholangiocarcinoma) neoplasms. Clinical pictures and even imaging patterns may be similar, requiring refined studies aiming at histopathological and immunohistochemistry for more precise diagnosis, essential for correct patient management. This article discusses updated concepts and definitions of most relevant entities aiming more specifically at the differential diagnosis in practice, focusing on morphology and immunohistochemistry, with a discussion of potential markers to help distinguishing between benign and malignant lesions.

RESUMO As proliferações biliares intra-hepáticas representam um espectro que abrange desde entidades reativas (reação ductular, algumas com arquitetura atípica), hamartomatosas (complexo de von Meyenburg), benignas (adenoma de ductos biliares) e precursoras/limítrofes (neoplasia intraepitelial biliar, neoplasia papilar intraductal de ducto biliar) até neoplasias totalmente malignas (colangiocarcinoma). Os quadros clínicos e até mesmo os padrões de imagem podem ser semelhantes, exigindo estudos refinados visando critério histológicos e imuno-histoquímicos para diagnósticos mais precisos, essenciais para o correto manejo do paciente. Este artigo discute conceitos atualizados e definições das entidades mais relevantes visando mais especificamente ao diagnóstico diferencial na prática, com foco na morfologia e imuno-histoquímica, com discussão de potenciais marcadores para ajudar na distinção entre lesões benignas e malignas.

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Introducción. Las neoplasias quísticas mucinosas del hígado son tumores poco frecuentes, equivalen a menos del 5 % de todas las lesiones quísticas hepáticas y se originan generalmente en la vía biliar intrahepática, con poco compromiso extrahepático. En la mayoría de los casos su diagnóstico es incidental dado que es una entidad generalmente asintomática con un curso benigno; sin embargo, hasta en el 30 % pueden ser malignas. En todos los casos se debe hacer una resección quirúrgica completa de la lesión. Caso clínico. Se presentan dos pacientes con diagnóstico de neoplasia quística mucinosa en la vía biliar intrahepática, así como sus manifestaciones clínicas, hallazgos imagenológicos y tratamiento. Discusión. Debido a su baja incidencia, esta patología constituye un reto diagnóstico, que se puede confundir con otro tipo de entidades más comunes. El diagnóstico definitivo se hace de forma histopatológica, pero en todos los casos, ante la sospecha clínica, se recomienda la resección completa. Conclusión. Se presentan dos pacientes con diagnóstico de neoplasias quísticas mucinosas del hígado, una entidad poco frecuente y de difícil diagnóstico

Introduction. Mucinous cystic neoplasms of the liver are rare tumors, accounting for less than 5% of all liver cystic lesions, and generally originate from the intrahepatic bile duct with little extrahepatic involvement. In most cases its diagnosis is incidental since it is a generally asymptomatic entity with a benign course; however, up to 30% can have a malignant course. In all cases, complete surgical resection of the lesion must be performed. Clinical case. Two patients with a diagnosis of mucinous cystic neoplasm in the intrahepatic bile duct are presented, as well as their clinical manifestations, imaging findings, and treatment. Discussion. Due to its low incidence, this pathology constitutes a diagnostic challenge, which can be confused with other types of more common entities. The definitive diagnosis is made histopathologically, but in all cases, given clinical suspicion, complete resection is recommended. Conclusion. Two patients with a diagnosis of mucinous cystic neoplasms of the liver are presented, a rare entity that is difficult to diagnose

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Bilomas are collections of bile outside the biliary tree. The most frequent etiologies are iatrogenic and trauma. Cases of spontaneous or atraumatic bilomas are rare. Management of bilomas depends on the size and location and may include monitoring only; if the size is < 4 cm, there may be percutaneous or endoscopic intervention. The use of antibiotics depends on the clinical status of the patient. We describe the case of a man who presented with a spontaneous biloma eight years after laparoscopic cholecystectomy and, in addition to signs of choledocholithiasis, a stricture of the common bile duct. In patients with symptoms of biliary pathology, the diagnosis of biloma should be considered even without a history of trauma or recent surgery to initiate appropriate treatment early. Many cases are asymptomatic and resolve spontaneously but occasionally require percutaneous or endoscopic management.

Los biliomas son colecciones de bilis fuera del árbol biliar. Las etiologías más frecuentes son la iatrogenia y el trauma. Los casos de biliomas espontáneos o atraumáticos son poco frecuentes. El manejo de los biliomas depende del tamaño y la localización y puede incluir vigilancia solamente, si el tamaño es < 4 cm, puede haber intervención percutánea o endoscópica. El uso de antibióticos depende del estado clínico del paciente. Presentamos el caso de un hombre que presentó un bilioma espontáneo 8 años después de una colecistectomía laparoscópica que, además de signos de coledocolitiasis, presentaba una estenosis del conducto biliar común. En los pacientes con clínica de patología biliar debe considerarse el diagnóstico de bilioma aun en los casos que no presenten antecedente de trauma o cirugía reciente con el fin de iniciar el tratamiento adecuado tempranamente. Muchos casos son asintomáticos y se resuelven espontáneamente, pero en ocasiones requieren manejo percutáneo o endoscópico.

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ABSTRACT Introduction: many revascularization techniques were designed to reduce the imbalance of ischemia-reperfusion injury. This study's objective is to evaluate retrograde reperfusion (RR) compared to sequential anterograde reperfusion (AR), with and without the washout technique (WO). Method: this prospective cohort study collected data from 94 deceased donor orthotopic liver transplants and divided it into three groups: RR with WO (RR+WO), AP with WO (AR+WO), and AP without WO (AR). This study did not assign the reperfusion technique to the participants. The primary outcome considered the early graft dysfunction, and secondary outcomes included post-reperfusion syndrome (PRS), post-reperfusion lactate, surgery fluid balance, and vasoactive drug dose during the surgery. Results: 87 patients were submitted to the final analysis-29 in the RR+WO group, 27 in the AR+WO group, and 31 in the AR group. Marginal grafts prevalence was not significantly different between the groups (34% vs. 22% vs. 23%; p=0.49) and early graft dysfunction occurred at the same rate (24% vs. 26% vs. 19%; p=0.72). RR+WO reduced serum post-reperfusion lactate (p=0.034) and the incidence of significant PRS (17% vs. 33% vs. 55%; p=0.051), but norepinephrine dosing >0.5mcg/kg/min were not different during the surgery (20,7% vs. 29,6% vs. 35,5%, p=0.45). Conclusions: primary outcome was not significantly different between the groups; however, intraoperative hemodynamic management was safer using the RR+WO technique. We theorized that the RR+WO technique could reduce the incidence of PRS and benefit marginal graft survival following diseased donor orthotopic liver transplantation.

RESUMO Introdução: várias técnicas de reperfusão foram desenvolvidas a fim de reduzir o dano da lesão induzida por isquemia-reperfusão. Este estudo objetivou avaliar a reperfusão retrograda (RR) comparado com a reperfusão anterógrada (AR), com e sem a realização da técnica de lavagem do enxerto (WO). Métodos: coorte prospectiva com 94 transplantes ortotópicos de fígado de doador falecido divididos em três grupos: RR com WO (RR+WO), reperfusão anterógrada com WO (AR+WO), e AR sem WO (AR). Este estudo não designou a técnica de reperfusão entre os participantes. O desfecho primário considerou a disfunção precoce do enxerto, e os desfechos secundários incluíram a síndrome pós-reperfusão (SPR), lactato pós-reperfusão, balanço hídrico operatório, e uso de drogas vasoativas durante o ato peratório. Resultados: 87 pacientes foram submetidos para consolidação dos dados-29 no RR+WO, 27 no AR+WO, e 31 no AR. A prevalência de enxertos maginais não diferiu entre os grupos (34% vs 22% vs 23%; p=0,49). Disfunção precoce do enxerto ocorreu em uma proporção similar (24% vs 26% vs 19%; p=0,72). RR+WO reduziu o lactato sérico pós-reperfusão (p=0,034) e a incidência de SPR severa (17% vs 33% vs 55%; p=0,051), entretanto a infusão de noradrenalina >0,5mcg/kg/min não foi diferente durante a cirurgia (20,7% vs 29,6% vs 35,5%, p=0,45). Conclusões: o desfecho primário não diferiu significativamente entre os grupos; entretanto, o manejo hemodinâmico intra-operatório foi mais seguro no grupo RR+WO. Nós teorizamos que a técnica RR+WO pode reduzir a SPR e beneficiar enxertos marginais no transplante de fígado.

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Introducción. Aproximadamente el 5 % de los divertículos duodenales pueden causar síntomas y el 1 % presentar complicaciones, siendo la colangitis la más frecuente. El síndrome de Lemmel corresponde a un tipo de ictericia obstructiva intermitente, asociado a la presencia de divertículos periampulares y disfunción del esfínter de Oddi, sin presencia de coledocolitiasis. Método. Se realizó una revisión sistemática de la literatura en Pubmed, Google Académico y ProQuest, con los términos: síndrome de Lemmel, divertículo duodenal sintomático e ictericia obstructiva intermitente. Resultados. Se encontraron 38 casos, siendo España el país con mayor número, seguido de México, Japón y Colombia. No hay diferencias de distribución con respecto al género. El tratamiento más frecuentemente empleado fue la colangio pancreatografia retrógrada endoscópica. Conclusión. El síndrome de Lemmel es poco frecuente, sin un cuadro clínico especifico, con un incremento en los casos informados en los últimos años, posiblemente debido a la mejor disponibilidad de métodos diagnósticos. Es más frecuente en pacientes en la octava década de la vida y su tratamiento generalmente es endoscópico

Introduction. Approximately 5% of duodenal diverticula can cause symptoms and 1% have complications, cholangitis being the most common. Lemmel syndrome corresponds to a type of intermittent obstructive jaundice, associated with the presence of peri-ampullary diverticula and sphincter of Oddi dysfunction, without choledocholithiasis. Method. A systematic review of the literature was carried out in Pubmed, Google Scholar, ProQuest, with the terms: Lemmel syndrome, symptomatic duodenal diverticulum, and intermittent obstructive jaundice.Results. 38 cases were found, Spain being the country with the highest number, followed by Mexico, Japan and Colombia. There are no differences in distribution with respect to gender. The most frequently used treatment was endoscopic retrograde cholangiopancreatography.Conclusion. Lemmel syndrome is a rare disease, without a specific clinical presentation, with an increase in reported cases in recent years possibly due to the better availability of diagnostic methods. It is more frequent in patients in the eighth decade of life and its treatment is generally endoscopic

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