Biliary Infections: Spectrum of Imaging Findings and Management

Infectious cholangitides encompass a wide spectrum of infectious processes affecting the biliary tree. They can have protean clinical and imaging appearances. Some manifest as an acute medical emergency with high mortality if not properly and emergently managed. Others are chronic processes that may predispose a patient to liver failure or cholangiocarcinoma. The clinical and imaging features and the subsequent therapy are dictated by the pathogens involved, the immune status of the host, and the degree and distribution of biliary obstruction. Bacteria cause most cases of infectious cholangitis in Western countries. In other parts of the world, parasites play an important role, either as causative agents or in predisposing the host to bacterial superinfection. Viral cholangitides primarily affect immunocompromised patients. The clinical and imaging features of cholangitis differ between immunocompetent and immunocompromised patients. Imaging plays a pivotal role in diagnosis of infectious cholangitis, helps identify predisposing causes, and demonstrates complications. Moreover, interventional radiology provides tools to treat acute life-threatening biliary infections, chronic entities, and complications. (C) RSNA, 2009.radiographics.rsna.or

Consensus statement on the pathology of IgG4-related disease

IgG4-related disease is a newly recognized fibro-inflammatory condition characterized by several features: a tendency to form tumefactive lesions in multiple sites; a characteristic histopathological appearance; and-often but not always-elevated serum IgG4 concentrations. An international symposium onIgG4-related disease was held in Boston, MA, on 4-7 October 2011. The organizing committee comprising 35 IgG4-related disease experts from Japan, Korea, Hong Kong, the United Kingdom, Germany, Italy, Holland, Canada, and the United States,including the clinicians, pathologists, radiologists, and basic scientists. This group represents broad subspecialty expertise in pathology, rheumatology, gastroenterology, allergy, immunology, nephrology, pulmonary medicine, oncology, ophthalmology, and surgery. The histopathology of IgG4-related disease was aspecific focus of the international symposium. The primary purpose of this statement is to provide practicing pathologists with a set of guidelines for the diagnosis of IgG4-related disease. The diagnosis of IgG4-related disease rests on the combined presence of the characteristic histopathological appearance and increased numbers of IgG4(+) plasma cells. The critical histopathologicalfeatures are a dense lymphoplasmacytic infiltrate, a storiform pattern of fibrosis, and obliterative phlebitis. We propose a terminology scheme for the diagnosis of IgG4-related disease that is based primarily on the morphological appearance on biopsy. Tissue IgG4 counts and IgG4:IgG ratios are secondary inimportance. The guidelines proposed in this statement do not supplant careful clinicopathological correlation and sound clinical judgment. As the spectrum of this disease continues to expand, we advocate the use of strict criteria for accepting newly proposed entities or sites as components of the IgG4-related disease spectru

Role of biologics and other therapies in stricturing Crohn's disease: what have we learnt so far?

Background: Therapy of strictures, one of the most common complications of Crohn\u2019s disease (CD), remains a challenging task in gastroenterology. While infliximab is widely recognized as being very effective in active CD, it has been reported to cause strictures in some patients. As a consequence, essentially by inference, many clinicians have chosen not to use it in the presence of strictures. Aims: To find evidence in the available data that infliximab does not cause strictures and that there is no rational basis to avoid its a priori use when a stricture is already present. In addition, to review what is currently known on the general management of strictures in CD. Methods: Discussion of the data that led to the hypothesis of a causal association between infliximab and strictures. Review of the mechanisms and the risk factors for stricture development in CD; of the different types of CDrelated strictures; of the available means to distinguish them, and of the literature related to the efficacy and safety of infliximab as well as other biologics and other therapies in different stricturing scenarios. Results and Conclusions: Although larger controlled studies are due in the near future, current evidence indicates that infliximab does not cause strictures in CD. The drug appears safe and effective in the presence of an inflammatory stenosis while being predictably ineffective, but not harmful, in the presence of fibrosis. Different stricturing scenarios in CD must be clearly distinguished for proper management of this complication