Bacteriology of war wounds at the time of injury

Bacterial contamination of war wounds occurs either at the time of injury or during the course of therapy. Characterization of the bacteria recovered at the time of initial trauma could influence the selection of empiric antimicrobial agents used to prevent infection. In the spring of 2004, U.S. military casualties who presented to the 31st Combat Support Hospital in Baghdad, Iraq, with acute traumatic injuries resulting in open wounds underwent aerobic culture of their wounds to identify the bacteria colonizing the wounds. Forty-nine casualties with 61 separate wounds were evaluated. Wounds were located predominantly in the upper and lower extremities and were primarily from improvised explosive devices or mortars. Thirty wounds (49%) had bacteria recovered on culture, with 40 bacteria identified. Eighteen casualties (20 wounds) had undergone field medical therapy (irrigation and/or antimicrobial treatment); six of these had nine bacterial isolates on culture. Of the 41 wounds from 31 patients who had received no previous therapy, 24 grew 31 bacteria. Gram-positive bacteria (93%), mostly skin-commensal bacteria, were the predominant organisms identified. Only three Gram-negative bacteria were detected, none of which were characterized as broadly resistant to antimicrobial agents. The only resistant bacteria recovered were two isolates of methicillin-resistant Staphylococcus aureus (MRSA). Our assessment of war wound bacterioly soon after injury reveals a predominance of Gram-positive organisms of low virulence and pathogenicity. The presence of MRSA in wounds likely reflects the increasing incidence of community-acquired MRSA bacteria. These data suggest that the use of broad-spectrum antibiotics with efficacy against more resistant, Gram-negative bacteria, such as Pseudomonas aeruginosa and Acinetobacter spp., is unnecessary in early wound management.     

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p = 0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p = 0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.     

Cryptosporidiosis of the biliary tract in AIDS

Cryptosporidiosis of the biliary system was studied retrospectively in 13 patients with acquired immunodeficiency syndrome (AIDS). The diagnosis was made by means of histologic examination (n = 9) or imaging studies and the presence of intestinal cryptosporidiosis (n = 4). Imaging studies were done in 10 patients. Ultrasound (US) and computed tomography (CT) showed dilatation of the biliary ducts, some with wall thickening, thickening of the gallbladder wall and pericholecystic fluid. Cholangiograms showed attenuation and pruning of the intrahepatic bile ducts, some with beading and dilatation of the common bile duct. Three patients had papillary stenosis. Numerous Cryptosporidium organisms were found in three resected gallbladders and in the biliary ducts of seven patients in whom autopsy was performed, accompanied by an exuberant inflammatory response. Correlation of the radiologic and pathologic findings establishes a direct etiologic role of Cryptosporidium as one of the major infectious agents in cholangitis associated with AIDS.     

Computed tomographic diagnosis of obstructive jaundice in the absence of intrahepatic ductal dilatation.

Six patients with obstructive jaundice had computed tomography (CT) scans showing a dilated extrahepatic biliary tree in the absence of intrahepatic ductal dilatation. Dilated extrahepatic bile ducts were most easily identified by means of intravenous injection of urographic contrast material, which permitted them to be seen as low density structures. Findings in these patients emphasize that (1) demonstration of dilated intrahepatic bile ducts is not a prerequisite for the CT diagnosis of obstructive jaundice and (2) careful CT evaluation of the extrahepatic biliary tree is necessary to identify patients with isolated dilatation of the common hepatic or common bile duct.     

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p = 0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p = 0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.     

Mucin-hypersecreting intrahepatic biliary neoplasms

The radiologic findings are described in six patients with "mucin-hypersecreting" intrahepatic biliary neoplasms (biliary cystadenocarcinoma or papillary cholangiocarcinoma). Massive amounts of mucin were confirmed in the dilated bile ducts at surgery or autopsy. Computed tomography (CT) and ultrasound (US) demonstrated severe dilatation of the intrahepatic bile ducts distal to the tumor in all patients and of extrahepatic ducts in five. On cholangiograms, large, amorphous filling defects caused by retention of mucin were found in the dilated ducts in three patients. The tumor was multilocular and cystic in five patients; in the other patient it was too small to be detected at CT or US. The presence of liver tumor (mostly multilocular and cystic), marked biliary dilatation distal to the tumor, and filling defects in the dilated bile ducts are important findings that indicate a mucin-hypersecreting intrahepatic biliary neoplasm.     

Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography

OBJECTIVE: The purpose of our study was to compare the accuracy of helical CT cholangiography and that of MR cholangiography in the diagnosis of aberrant bile ducts or cystic ducts before laparoscopic cholecystectomy. SUBJECTS AND METHODS: A total of 120 consecutive patients, including 114 patients with cholecystolithiasis and six with gallbladder polyps, were treated using laparoscopic cholecystectomy between November 1996 and August 1998. Eighteen (15%) of the 120 patients were suspected of having aberrant bile ducts or cystic ducts on helical CT cholangiography, and 16 of these 18 patients were subsequently examined on MR cholangiography. For the 16 patients who underwent both imaging examinations, findings from helical CT cholangiography and MR cholangiography were compared with intraoperative cholangiography. RESULTS: Aberrant bile ducts in 13 patients and aberrant cystic ducts in three patients were divided into six types on the basis of the results of intraoperative cholangiography. Although these types were clearly identified using helical CT cholangiography in all 16 patients, the anatomic variants were not correctly identified in seven (44%) of the 16 patients with MR cholangiography. False-negative findings were mainly a result of the insertion sites of the cystic ducts or aberrant bile ducts being obscured by aberrant bile ducts or duodenum. Two (2%) of the 120 patients developed mild adverse reactions to the contrast material, but neither required treatment. CONCLUSION: Helical CT cholangiography clearly showed aberrant bile ducts and cystic ducts, but visualization of these structures on MR cholangiography was unsatisfactory because of overlapping duodenum and hepatic ducts.     

Comparative diagnostic evaluation with MR cholangiopancreatography, ultrasonography and CT in patients with pancreatobiliary disease

Purpose

The aim of this study was to directly compare the results of magnetic resonance cholangiopancreatography (MRCP) with those of ultrasonography (US) and multislice computed tomography (MSCT) in the diagnosis of pancreaticobiliary diseases.

Materials and methods

A total of 70 patients (41 men, 29 women) aged 22-89 years were studied either before (n=59) or after cholecystectomy (n=11) for biliary lithiasis. Clinical signs and symptoms were jaundice (n=15), abdominal pain (n=37) and proven biliary lithiasis (n=18). MRCP was performed in all patients, whereas abdominal US was performed in 55 (group 1) and MSCT in 37 (group 2) patients. A regional evaluation of the main structures of the pancreaticobiliary system was performed: gallbladder and cystic duct, intra- and extrahepatic bile ducts and main pancreatic duct. Histology (n=27), biopsy (n=5), endoscopic retrograde cholangiopancreatography (ERCP) (n=28) and/or clinical-imaging follow-up (n=10) were considered standards of reference. In particular, patients were classified as showing benign (n=47) or malignant (n=12) lesions or normal biliary anatomy (n=11).

Results

In group 1, the results of MRCP and US were concordant in the majority (92%) of cases; however, statistically significant discordance (p<0.01) was found in the evaluation of the extrahepatic ducts, with nine cases (16%) of middle-distal common bile duct stones being detected on MRCP only. In group 2, the results of MRCP and MSCT were also concordant in most cases (87%). However, findings were significantly discordant when the intra- and extrahepatic ducts were analysed, with seven (19%) and six (16%) cases, respectively, of lithiasis being detected on MRCP only (p<0.01 for both).

Conclusions

The results of our study confirm the diagnostic potential of MRCP in the study of the pancreaticobiliary duct system. In particular, the comparison between MRCP and US and MSCT indicates the superiority of MRCP in evaluating bile ducts and detecting stones in the common bile duct.     

Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts

OBJECTIVE: We evaluated the technical success and complications of percutaneous transhepatic biliary drainage in patients with nondilated intrahepatic bile ducts. MATERIALS AND METHODS: Between January 1, 1996, and August 31, 1998, 130 percutaneous transhepatic biliary drainage procedures were performed on patients with nondilated intrahepatic bile ducts. This group comprised primarily patients who had received liver transplants or who had sustained iatrogenic bile duct injuries. Access in all procedures was performed using a one-step system consisting of a 21-gauge needle and an .018-inch guidewire. The technical success and complications of the procedures were evaluated. RESULTS: Percutaneous biliary drainage was successful in 117 (90%) of 130 attempts. In four patients, two attempts were required to place a drainage catheter. The overall complication rate was 9%. There were seven (5%) minor complications and five major complications (4%). No procedure-related deaths occurred. CONCLUSION: Percutaneous biliary drainage can be performed with a high success rate in patients with nondilated intrahepatic ducts. The incidence and types of complications in this population were similar to those reported in patients with intrahepatic ductal dilatation.     

Transcholecystic Contrast-Enhanced Ultrasound-Guided Percutaneous Transhepatic Biliary Drainage for Central Bile Duct Protection During Thermal Tumor Ablation

Intraductal cooling via a percutaneous transhepatic biliary drainage tube holds great promise in facilitating thermal ablation of liver tumors adjacent to the central bile ducts. However, the difficulties and complications associated with puncturing nondilated bile ducts are greater than those associated with puncturing dilated bile ducts. As reported here, percutaneous transcholecystic contrast-enhanced ultrasound was performed in 7 patients to visualize the nondilated bile ducts and guide percutaneous transhepatic biliary drainage, thus facilitating the intraductal cooling-assisted thermal ablation process. The procedures were technically successful in all 7 patients, and no major complications were recorded during the follow-up period.     

螺旋CT胆道立体成像对胆道梗阻性疾病诊断价值的研究

目的 评价螺旋CT胆道立体成像对胆道梗阻性疾病的诊断价值。材料与方法 静脉注射胆道对比剂Biliscopin,对胆道不显影者给予血管对比剂。83例胆道梗阻性疾病患者均行上腹部螺旋CT容积扫描,在工作站利用软件将图像处理后得到胆道系统立体图像。结果 50例胆道显影者中,以胆管结石、炎症和胰腺炎致胆道梗阻多见,占48例;33例胆道不显影者中,以胆管癌、胰头或壶腹癌多见,占23例。螺旋CT胆道立体成像可以很好显示梗阻部位以上胆管扩张的程度和形态,可准确确定梗阻部位以及梗阻的原因,区别肿瘤、结石或炎症等。结论 螺旋CT胆道立体成像作为一种准确而无创伤性的检查方法,对胆道梗阻性疾病的诊断具有重要意义。     

MRCP在胆胰疾病中的应用

目的：评价ＭＲＣＰ技术在胆胰疾病中的应用价值。材料和方法：２２例胆胰疾病患者采用快速自旋回波和重Ｔ２加权技术进行ＭＲＣＰ扫描,获得原始图像经最大信号强度投影（ＭＩＰ）及三维表面重建（３Ｄ－ＳＳＤ）后处理。结果：２２例患者ＭＲＣＰ成功率为１００％,１８例梗阻性黄疸均能显示梗阻部位及扩张胆管,４例非梗阻性黄疸患者可满意显示正常胆总管及左右肝管主干。结论：ＭＲＣＰ能较好显示胆系解剖及病变部位与性质,创伤小,且成像技术简单,检查时间短,目前已成为胆胰系统疾病诊断的重要检查方法。     

Cholangiopathy in extrahepatic portal venous obstruction. Radiological appearances

PURPOSE: To evaluate cholangiographic abnormalities resulting from extrahepatic portal venous obstruction (EHPVO) by sonography and endoscopic retrograde cholangiopancreaticography (ERCP). MATERIAL AND METHODS: Forty-three patients with an established diagnosis of EHPVO were subjected to duplex Doppler sonography and ERCP. Of these, 8 patients had obstructive jaundice. RESULTS: Dilated common bile duct with pericholedochal varices showing a continuous type of flow pattern was seen in 5 EHPVO patients with obstructive jaundice. ERCP revealed cholangiographic abnormalities in 40 patients (93%). Extrahepatic bile ducts were involved in 100% of cases compared to intrahepatic bile ducts (57%). Abnormalities noted were contour irregularity with indentations, displacement and angulation, strictures and filling defects in the extrahepatic ductal system. Intrahepatic bile ducts showed dilatation with areas of narrowing and filling defects. CONCLUSION: Cholangiographic abnormalities are very common in patients with EHPVO, even without clinical manifestations of biliary disease. Extrahepatic bile ducts are far more often involved compared to intrahepatic bile ducts. Extrinsic compression with contour irregularity is the most common cholangiographic finding. Sonographic findings are not diagnostic. Dilated common bile duct with pericholedochal varices was seen in only 5 patients.     

超声对华支睾吸虫感染所致胆道梗阻的诊断价值

目的 探讨华支睾吸虫感染所致胆道梗阻的超声影像特点及其诊断价值.资料与方法 回顾性分析43例华支睾吸虫感染患者的胆道梗阻声像图表现,并与胆总管病变引起的胆道梗阻作比较.结果 43例华支睾吸虫感染所致胆道梗阻患者均表现为肝内胆管轻至中度扩张,以次级胆管明显,胆管壁增厚,回声增强,胆囊肿大,胆总管轻度扩张,扩张程度与肝内胆管不成正比.胆总管病变引起的胆道梗阻其肝内胆管扩张程度与胆总管成正比.结论 华支睾吸虫感染所致胆道梗阻超声表现具有特征性,超声可作为该病的有效诊断方法.     

阴性法64层CT胆胰管成像在胆道闭锁中的诊断价值

目的：总结分析胆道闭锁的阴性法64层CT胆胰管成像（N—CTCP）的影像表现,探讨其诊断价值。方法：回顾性分析临床疑诊为胆道闭锁的52例患儿的影像资料,全部患儿行腹部增强CT门脉期扫描后采用容积重建（VR）、多平面重建（MPR）及最小密度投影（MinlP）等技术进行重建,观察并比较患儿肝内外胆道、肝门部结构、胆囊、肝脏、脾脏大小等征象的显示情况。结果：32例经手术病理证实为胆道闭锁（BA组）,20例临床确诊为婴儿肝炎综合征（IHS组）。胆道闭锁的N—CTCP影像特征包括：无或小胆囊、肝门区三角形低密度区、门静脉间隙增宽,可见“双边征”或“靶征”。BA组无1例显示胆总管,4例左、右肝管可见,但管道不连续,20例出现肝、脾肿大。小胆囊、三角征及门静脉间隙增宽在IHS组与BA组中差异有统计学意义（P〈O．05）,肝外胆管不显示、肝脾肿大在IHS组与BA组间差异无统计学意义（P〉0．05）。结论：胆道闭锁的N—CTCP表现具有一定特征性,肝门区三角形低密度影、小胆囊、门静脉间隙增宽出现“双边征”或“靶征”是诊断BA的重要征象。     

MR cholangiography in children and young adults with biliary disease

OBJECTIVE: Our objective was to describe the MR cholangiography findings for young patients with suspected biliary disease who underwent half-Fourier acquisition fast spin-echo technique with respiratory triggering. SUBJECTS AND METHODS: Twenty-eight MR cholangiography studies were performed in 22 patients on a 1.5-T MR unit. Ten of these 22 patients had undergone liver transplantation. RESULTS: MR cholangiography revealed abnormalities of both the extrahepatic and the intrahepatic major and minor bile duct systems, despite the small diameter of the duct system in this group of patients. Four patterns of biliary disease were shown: global dilatation of extrahepatic or intrahepatic ducts (n = 7); segmental, uniform dilatation of central or peripheral intrahepatic ducts (n = 9); segmental, nonuniform dilatation of central or peripheral intrahepatic ducts (n = 2); and fusiform ectasia with segmental, irregular intrahepatic dilatation and bile lakes (n = 2). The findings of eight studies were interpreted as normal. The four patterns of abnormalities were correlated with the results from percutaneous transhepatic cholangiography, T-tube cholangiography, and liver biopsy and with clinical and surgical information, as available. CONCLUSION: MR cholangiography is a noninvasive technique for evaluation of biliary disease. The improved resolution afforded by respiratory triggering permits evaluation of both major and minor bile ducts, even in young, uncooperative subjects. Four patterns of abnormalities were prospectively identified, correlated with other information, and used to direct clinical treatment.     

Technical problem: impacted retained distal common duct stone

We report a three-stage technique for use when impacted, retained distal common bile duct stones are encountered. It minimises instrumentation of the ampullary region during any one interventional session, provides drainage of biliary and pancreatic ducts between sessions and, in our opinion, maximises the chances of safely extracting such a stone.     

胆汁细菌学检验及其对抗生素的耐药性分析

目的　了解胆道感染常见病原菌的种类及其对常用抗生素的耐药性 ,以指导临床合理用药。　方法　将 1998年 1月至 2 0 0 2年 6月间 6 9例住院病人胆汁培养阳性的 73株需氧菌及其对抗生素敏感性试验结果进行统计分析。　结果　标本的阳性检出率为 70 .4 % ,在分离株中 ,大多数病原菌为大肠埃希菌、肺炎克雷伯菌和肠球菌。革兰氏阴性杆菌对亚胺培南、阿米卡星和头孢他啶较为敏感 ,阳性球菌对万古霉素全部敏感。　结论　引起胆道感染的常见的需氧菌为大肠埃希菌、肺炎克雷伯菌和肠球菌 ,治疗时应根据药敏选择抗生素 ,必要时联合用药     

Percutaneous cholecystography in children

Percutaneous cholecystography was performed on 13 children who had biliary system abnormalities: two had biliary hypoplasia, five had sclerosing cholangitis, three had cirrhosis, two had distal choledochal obstruction, and one had an obstructed portoenterostomy. In 12 patients transcholecystic cholangiography showed, without significant complications, the intra-and extrahepatic bile ducts. In one patient with primary sclerosing cholangitis, the intrahepatic bile ducts were not opacified satisfactorily; dilatation of the gallbladder required surgical drainage. The transcholecystic technique is indicated when the intrahepatic bile ducts are either mildly dilated or not dilated.     

CT findings of clonorchiasis

Clonorchiasis is a snail-transmitted trematodiasis caused by Chinese liver fluke, Clonorchis sinensis. Forty-two patients with the disease were examined with CT. Seventeen patients had clonorchiasis alone, and 25 patients had clonorchiasis with hepatobiliary malignancies (20 cholangiocarcinomas, four hepatocellular carcinomas, one carcinoma of the ampulla of Vater). In three of the 17 patients with clonorchiasis alone, the CT scans were normal. In 14 patients (82%), CT showed diffuse, minimal, or mild dilatation of the intrahepatic bile ducts. None of the patients had marked dilatation. The extrahepatic biliary tree was normal in all 17 patients. All 25 patients with clonorchiasis and hepatobiliary malignancies had diffuse dilatation of the intrahepatic bile ducts on CT, including 18 patients with minimal or mild dilatation and seven patients with marked dilatation. All seven patients with marked dilatation had extrahepatic biliary malignancies. Clonorchis sinensis per se or thickening of the bile duct wall could not be recognized on CT scans. Additional abnormalities evident on CT included pyogenic liver abscesses in two patients and gallstones in five patients. The diagnosis of clonorchiasis can be suspected when CT shows diffuse, uniform, and minimal or mild dilatation of the intrahepatic bile ducts, particularly in the periphery of the liver, without evidence of extrahepatic biliary dilatation.