Biliary lithiasis is a metabolic disease that many risk factors participate of the etiopathogeny, and potentialize an eventual genetic condition. Prevalence in the western countries is about 10-15% of adults, being an important public health trouble. There is no knowledge about its pathogenesis yet, that can be associated to an unusual metabolism of cholesterol and lipoproteins. This study had aims to verify the relationship between serum and biliary levels of protein, cholesterol and calcium in patients with gallstones and gallbladder polip; identify if there is difference between laboratorial serum and biliary concentration of this elements in these two groups; study laboratorial serum and biliary profile in gallstones patients through of protein, cholesterol and calcium levels. This transversal study had two groups: a 41 gallstones patients and a 15 gallbladder polip patients as control group. Everyone was submitted to a videolaparoscopic cholecystectomy, when they had been taken blood and bile samples to be analyzed. In the blood was measured cholesterol total, LDL, HDL fractions, triglycerides, calcium total and protein total. In the bile was measured cholesterol total, calcium total and proteins. Statistical analysis was composed by use of F - test to normal distribution, Levene test to abnormal distribution. Student s t - test to medias comparison, analysis of variance of factor and Pearson correlation test p<0,05 was considered significant. It was found a stronger correlation between three elements measured in gallstone group. In polip group was found a strong correlation between calcium and protein biliary. There is no correlation between serum and biliary elements in gallstone group: calcium, cholesterol, LDL, HDL. Polip group had correlation between biliary protein and LDL serum, calcium biliary and HDL serum.With exception of protein and calcium biliary, more elevated in polip patients, every elements had statistics medias equals. Conclusions: there was no correlation between lipids elements bilia ries and serum in both studied groups; the medias of biliary and serum contents were statistically the same, with exception of protein and calcium biliary, had more elevated levels in polip group. The profile of serum and biliary elements was similar in both groups except for the biliary protein and of the triglycerids that presents some difference. / Litiáse biliar é uma doença metabólica, de cuja etiopatogenia participam vários fatores de risco, que potencializam uma eventual condição genética. A prevalência nos países ocidentais atinge 10 a 15% da população adulta, produtiva, configurando um importante problema de saúde pública. Não se tem ainda um total esclarecimento sobre sua patogênese, que pode estar associada a anormalidades no metabolismo do colesterol e das lipoproteínas. Este trabalho teve como objetivos verificar se há relação entre níveis séricos e biliares da proteína, do colesterol e do cálcio em portadores de colelitíase e de pólipo da vesícula; identificar se há diferença entre os valores laboratoriais séricos e biliares desses elementos obtidos nos dois grupos; estudar o perfil laboratorial sérico e biliar de pacientes portadores de colelitíase, a partir dos elementos supracitados. Esse estudo transversal envolveu 41 pacientes com colelitíase e 15 com pólipos da vesícula biliar como grupo de controle. Todos se submeteram a colecistectomia videolaparoscópica e tiveram amostras de sangue e bile colhidas para análise. Foram dosados no sangue: colesterol total, LDL, HDL, triglicérides, cálcio total e proteínas totais. Na bile dosaram-se: colesterol total, cálcio total e proteínas. A análise estatística consistiu na aplicação do teste F para distribuição normal e de Levene para distribuição não normal, teste t de Student para comparação das médias, análise de variância de um fator e teste de correlação de Pearson. Considerou-se um nível de significância p<0,05. Foram encontradas correlações fortíssimas entre os três elementos biliares pesquisados no grupo de cálculo. No grupo de pólipo houve correlação forte entre proteína e cálcio biliares. Constatou-se a inexistência de correlação, no grupo de cálculo, entre os elementos biliares e os séricos: cálcio, colesterol, LDL e HDL. No grupo de pólipo, houve correlação forte entre proteína biliar e LDL sérico, cálcio biliar e HDL sérico. Com exceção da proteína e do cálcio biliares, mais elevados nos pacientes com pólipo, todos os elementos biliares e séricos dosados tiveram médias estatisticamente iguais. Chegou-se às seguintes conclusões: não houve correlação entre os elementos lipídicos biliares e séricos nos dois grupos estudados; a média dos constituintes biliares e séricos foi estatisticamente igual, com exceção da proteína e do cálcio biliares, que tiveram níveis mais elevados no grupo de pólipo. O perfil dos elementos séricos e biliares foi semelhante nos dois grupos, exceto a proteína biliar e os triglicérides, que apresentaram diferença.

Abstract Biliary carcinoma, biliary fistula with occasional gallstone ileus and primary sclerosing cholangitis (PSC) are serious diseases and present specific diagnostic and therapeutic challenges. Stenting of biliary obstruction has also involved problems, but the reports are contradictory and partly limited. The aim of the present work was to evaluate and compare various imaging modalities in biliary diseases. The study also aimed to evaluate the usefulness of metallic stents in malignant biliary obstruction. The study population consisted of 210 patients with gallbladder carcinoma, bile duct carcinoma, biliary fistula, PSC or malignant biliary obstruction and eight control patients with various hepatobiliary diseases. The imaging findings of 80 patients with gallbladder carcinoma, 58 patients with bile duct carcinoma, and 16 patients with biliary fistula were reviewed. Nine patients with PSC underwent magnetic resonance cholangiography (MRC) and magnetic resonance imaging (MRI) of the liver, ultrasonography (US) of the liver and the bile ducts and endoscopic retrograde cholangiography (ERC). Eight control patients had had MRC and MRI of the liver and ERC. The medical records and radiographs of 39 patients with malignant biliary obstruction treated with percutaneously inserted metallic stents were also analysed. The stents included 48 Wallstents and seven Memotherm stents. In cases of gallbladder carcinoma, US visualised the primary tumour in 68 % and computed tomography (CT) in 57 % of the cases examined, but both methods were insufficient for accurate staging. In bile duct carcinoma, US revealed the primary tumour in 63 % and CT in 44 % of the cases examined. Both methods were sensitive in diagnosing peripheral intrahepatic cholangiocarcinoma, but inaccurate for more distal bile duct carcinoma or abdominal spread. The infiltrating type of gallbladder carcinoma and bile duct carcinoma were difficult to detect. US and CT were sensitive in revealing bile duct obstruction. The patients with biliary fistula and gallstone ileus had undergone various examinations with pathological, but not diagnostic results, and there was often a delay to diagnosis. Imaging did not reveal any of the ten spontaneous fistulas, but CT showed one of the five cases of gallstone ileus, and Gastrografin® meal revealed the single case of Bouveret's syndrome. Fistulography or cholangiography revealed all but one of the six iatrogenic fistulas. A nonvisualised or shrunken gallbladder at US should raise a suspicion of biliary enteric fistula in an appropriate clinical setting. MRC-MRI depicted the changes of PSC correctly in nine patients (radiologist 1) and in eight patients with one false positive finding (radiologist 2) in a blinded analysis. In the segmental comparison MRC missed especially bile duct dilatations. MRC was too pessimistic in the evaluation of the predictors of poor outcome. US detected features suggestive of PSC in eight patients (radiologist 3). US was unable to indicate the predictors of poor outcome. Of the patients with metallic stents in malignant biliary obstruction, 30 % had early and 66 % late complications, including stent obstructions, which occurred in 27 % of the patients at a mean of 4.4 months. The cause was mostly tumour ingrowth or overgrowth. The 25-week and 50-week patency rates were 71 % and 42 %. The patency rates of the patients with cholangiocarcinoma were significantly the lowest. There was also a tendency towards lower patency with less dilatation of the stents, an increasing number of the stents, longer strictures and hilar strictures. Many other complications were infectious. 31 % of the patients had late reinterventions.

Introdução / Objetivos: O prognóstico do adenocarcinoma ampular pode ser influenciado por fatores como estadiamento e variáveis histopatológicas, como o padrão intestinal ou pancreatobiliar. O diagnóstico do padrão histopatológico pode ser auxiliado pela expressão de citoqueratinas, CK, 7 e 20 e do gene homeobox CDX2. O objetivo do estudo foi analisar associações entre características histopatológicas e sobrevida, e entre padrão histopatológico e expressão de CK7, CK20 e CDX2. Método: Estudo de coorte retrospectivo desenvolvido no Hospital de Clínicas de Porto Alegre entre 2000 e 2011. Foram avaliados dados histopatológicos, estadiamento pTNM, padrão histopatológico e expressão imunoistoquímica e sobrevida. Resultados: A amostra constou de 65 carcinomas ampulares (n = 65). Foi observado padrão intestinal em 46, pancreatobiliar em 16 e outros em três. Sobrevida em cinco anos após duodenopancreatectomia (n = 47) foi de 27%. Associaram-se à menor sobrevida na análise univariada: dois ou mais linfonodos metastáticos, razão de linfonodos, RL, maior ou igual a 20%; estágio IIB em relação a inferiores; tumor de alto grau; invasão linfovascular. Na análise multivariada, metástase linfonodal e RL ≥ 20% influenciaram sobrevida. Conclusões: O pior prognóstico foi associado à metástase linfonodal. Não foi observada associação entre padrão histopatológico e expressão imunoistoquímica. / Background / Objectives: The prognosis of patients with ampullary adenocarcinomas can be influenced by such factors as pTNM stage and histopathological variables, such as intestinal or pancreatobiliary patterns. The characterization of these patterns can be facilitated by the expression of cytokeratins 7 (CK7) and 20 (CK20) and caudal-related homeobox gene 2 (CDX2). The aim of the present study was to analyze the association between the histopathological characteristics and the survival of patients with ampullary adenocarcinomas, as well as the association between the histopathological patterns and CK7, CK20 and CDX2 expression. Methods: This retrospective cohort study was performed at the Clinics Hospital of Porto Alegre between 2000 and 2011 and examined the histopathological data, pTNM stage, histopathological patterns, immunohistochemical expression patterns and survival of patients with ampullary adenocarcinomas. Results: The sample patient population consisted of 65 ampullary carcinomas. Of these carcinoma samples, an intestinal pattern was observed for 46, a pancreatobiliary pattern was observed for 16 and other patterns were observed 3 of the samples. The 5-year survival rate for patients following pancreaticoduodenectomy (n = 47) was 27%. From the univariate analysis, the following variables were associated with shorter survival times: the presence of 2 or more metastatic lymph nodes; positive lymph node ratio (LR) ≥ 20%; stage IIB or greater; high-grade tumors; and lymphovascular invasion. From the multivariate analysis, lymph node metastases and a LR ≥ 20% were shown to influence survival significantly. Conclusions: Lymph node metastases were associated with poor patient prognoses, although no association was found between the histopathological pattern and immunohistochemical expression.

Introdução / Objetivos: O prognóstico do adenocarcinoma ampular pode ser influenciado por fatores como estadiamento e variáveis histopatológicas, como o padrão intestinal ou pancreatobiliar. O diagnóstico do padrão histopatológico pode ser auxiliado pela expressão de citoqueratinas, CK, 7 e 20 e do gene homeobox CDX2. O objetivo do estudo foi analisar associações entre características histopatológicas e sobrevida, e entre padrão histopatológico e expressão de CK7, CK20 e CDX2. Método: Estudo de coorte retrospectivo desenvolvido no Hospital de Clínicas de Porto Alegre entre 2000 e 2011. Foram avaliados dados histopatológicos, estadiamento pTNM, padrão histopatológico e expressão imunoistoquímica e sobrevida. Resultados: A amostra constou de 65 carcinomas ampulares (n = 65). Foi observado padrão intestinal em 46, pancreatobiliar em 16 e outros em três. Sobrevida em cinco anos após duodenopancreatectomia (n = 47) foi de 27%. Associaram-se à menor sobrevida na análise univariada: dois ou mais linfonodos metastáticos, razão de linfonodos, RL, maior ou igual a 20%; estágio IIB em relação a inferiores; tumor de alto grau; invasão linfovascular. Na análise multivariada, metástase linfonodal e RL ≥ 20% influenciaram sobrevida. Conclusões: O pior prognóstico foi associado à metástase linfonodal. Não foi observada associação entre padrão histopatológico e expressão imunoistoquímica. / Background / Objectives: The prognosis of patients with ampullary adenocarcinomas can be influenced by such factors as pTNM stage and histopathological variables, such as intestinal or pancreatobiliary patterns. The characterization of these patterns can be facilitated by the expression of cytokeratins 7 (CK7) and 20 (CK20) and caudal-related homeobox gene 2 (CDX2). The aim of the present study was to analyze the association between the histopathological characteristics and the survival of patients with ampullary adenocarcinomas, as well as the association between the histopathological patterns and CK7, CK20 and CDX2 expression. Methods: This retrospective cohort study was performed at the Clinics Hospital of Porto Alegre between 2000 and 2011 and examined the histopathological data, pTNM stage, histopathological patterns, immunohistochemical expression patterns and survival of patients with ampullary adenocarcinomas. Results: The sample patient population consisted of 65 ampullary carcinomas. Of these carcinoma samples, an intestinal pattern was observed for 46, a pancreatobiliary pattern was observed for 16 and other patterns were observed 3 of the samples. The 5-year survival rate for patients following pancreaticoduodenectomy (n = 47) was 27%. From the univariate analysis, the following variables were associated with shorter survival times: the presence of 2 or more metastatic lymph nodes; positive lymph node ratio (LR) ≥ 20%; stage IIB or greater; high-grade tumors; and lymphovascular invasion. From the multivariate analysis, lymph node metastases and a LR ≥ 20% were shown to influence survival significantly. Conclusions: Lymph node metastases were associated with poor patient prognoses, although no association was found between the histopathological pattern and immunohistochemical expression.

Introdução / Objetivos: O prognóstico do adenocarcinoma ampular pode ser influenciado por fatores como estadiamento e variáveis histopatológicas, como o padrão intestinal ou pancreatobiliar. O diagnóstico do padrão histopatológico pode ser auxiliado pela expressão de citoqueratinas, CK, 7 e 20 e do gene homeobox CDX2. O objetivo do estudo foi analisar associações entre características histopatológicas e sobrevida, e entre padrão histopatológico e expressão de CK7, CK20 e CDX2. Método: Estudo de coorte retrospectivo desenvolvido no Hospital de Clínicas de Porto Alegre entre 2000 e 2011. Foram avaliados dados histopatológicos, estadiamento pTNM, padrão histopatológico e expressão imunoistoquímica e sobrevida. Resultados: A amostra constou de 65 carcinomas ampulares (n = 65). Foi observado padrão intestinal em 46, pancreatobiliar em 16 e outros em três. Sobrevida em cinco anos após duodenopancreatectomia (n = 47) foi de 27%. Associaram-se à menor sobrevida na análise univariada: dois ou mais linfonodos metastáticos, razão de linfonodos, RL, maior ou igual a 20%; estágio IIB em relação a inferiores; tumor de alto grau; invasão linfovascular. Na análise multivariada, metástase linfonodal e RL ≥ 20% influenciaram sobrevida. Conclusões: O pior prognóstico foi associado à metástase linfonodal. Não foi observada associação entre padrão histopatológico e expressão imunoistoquímica. / Background / Objectives: The prognosis of patients with ampullary adenocarcinomas can be influenced by such factors as pTNM stage and histopathological variables, such as intestinal or pancreatobiliary patterns. The characterization of these patterns can be facilitated by the expression of cytokeratins 7 (CK7) and 20 (CK20) and caudal-related homeobox gene 2 (CDX2). The aim of the present study was to analyze the association between the histopathological characteristics and the survival of patients with ampullary adenocarcinomas, as well as the association between the histopathological patterns and CK7, CK20 and CDX2 expression. Methods: This retrospective cohort study was performed at the Clinics Hospital of Porto Alegre between 2000 and 2011 and examined the histopathological data, pTNM stage, histopathological patterns, immunohistochemical expression patterns and survival of patients with ampullary adenocarcinomas. Results: The sample patient population consisted of 65 ampullary carcinomas. Of these carcinoma samples, an intestinal pattern was observed for 46, a pancreatobiliary pattern was observed for 16 and other patterns were observed 3 of the samples. The 5-year survival rate for patients following pancreaticoduodenectomy (n = 47) was 27%. From the univariate analysis, the following variables were associated with shorter survival times: the presence of 2 or more metastatic lymph nodes; positive lymph node ratio (LR) ≥ 20%; stage IIB or greater; high-grade tumors; and lymphovascular invasion. From the multivariate analysis, lymph node metastases and a LR ≥ 20% were shown to influence survival significantly. Conclusions: Lymph node metastases were associated with poor patient prognoses, although no association was found between the histopathological pattern and immunohistochemical expression.

Background: Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) constitute rare chronic inflammatory biliary diseases which likely comprise genetic, environmental and autoimmune factors. Specific inhibitory (auto-) antibodies against the muscarinic acetylcholine receptor type 3 (mAChR3 auto-ab) may contribute to the pathogenesis of chronic biliary inflammation by modulating mAChR3− mediated signaling. Aims: The aim of this study was to analyze the prevalence and relevance of inhibitory mAChR3 auto-ab (mAChR3inh+ auto-ab) in a large cohort of PBC patients from two independent tertiary centers in Berlin and Leipzig in comparison to a large PSC cohort. Baseline parameters and response rates to standard treatment with ursodeoxycholic acid (UDCA) were characterized with respect to the individual mAChR3 auto-ab status. Methods: In total, the study population comprised 437 PBC patients, 187 PSC patients and 80 healthy controls. Clinical and laboratory baseline characteristics were retrieved from medical records. The response to ursodeoxycholic acid (UDCA) therapy after 12 months of treatment was available in 176 PBC and 45 PSC patients. Results: The prevalence of mAChR3inh+ auto-ab was significantly higher among PBC patients (11.2%, 49/437; p = 0.008 vs. healthy controls) and PSC patients (33.6%, 63/187; p < 0.0001 vs. healthy controls) compared to healthy controls (2.5%, 2/80), respectively. PBC patients with mAChR3inh+ auto-ab exhibited significantly higher levels of alkaline phosphatase (ALP) and bilirubin, which constitute established parameters for PBC risk stratification. Moreover, mAChR3inh+ PBC patients tended to show decreased response rates to UDCA therapy compared to PBC patients without mAChR3inh+ auto-ab (mAChR3− PBC). In contrast, PSC patients with mAChR3inh+ auto-ab showed no significant differences in laboratory findings compared to mAChR3 auto-ab negative (mAChR3−) PSC patients. Conclusion: MAChR3inh+ auto-ab might be involved in the pathogenesis and treatment response of chronic biliary inflammation in patients with PBC but not in patients with PSC.

published_or_final_version / Psychiatry / Master / Master of Philosophy

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / It is estimated over 20 million people aged 20‐74 have gallbladder disease, with biliary colic being a common and painful symptom in these patients. Likely due to the relatively recent approval of intravenous ibuprofen use for fever and pain in adults, no assessment of its analgesic efficacy for biliary colic currently exists in the literature. In this double‐blind, randomized, controlled trial we aim to assess the analgesic efficacy of intravenous (IV) ibuprofen given in the emergency department (ED) for the treatment of biliary colic. Analgesic efficacy was evaluated using a visual analog scale (VAS) to assess for a decrease in pain scores. A VAS score decrease of 33% in relation to the VAS taken at the time of therapy drug administration was considered a minimum clinically important difference (MCID) in patient‐perceived pain. A VAS was administered in triage upon enrollment, at the time of therapy administration, at 15‐minute intervals during the first hour post‐administration, and 30‐minute intervals in the second hour. As the standard of care for suspected biliary colic at the study institution is administration of a one‐time dose of IV morphine, patients were not denied initial morphine analgesia and were permitted to receive “rescue” morphine analgesia at any point during their ED course. A total of 22 patients completed the study. 9 were randomized to the IV ibuprofen arm, 9 to placebo, and 4 were excluded for a diagnosis other than biliary colic. Mean VAS values at time 0 to time 120 decreased from 5.78 to 2.31 in the ibuprofen group, and from 5.89 to 2.67 in the control group. There was no statistically significant difference in treatment status of ibuprofen vs. placebo (p‐value (p.) 0.93), though there was a significant decrease in the measured VAS scores over time (0 minutes to 120 minutes, p.0.031) in both ibuprofen and placebo groups. A statistically significant and clinically important decrease in average VAS scores were seen in both placebo and ibuprofen groups (55% and 60%, respectively). There was no difference in time needed to achieve a clinically significant reduction in pain between groups. The sample size of this study may be inadequate to fully assess the analgesic efficacy of IV ibuprofen for biliary colic. In the analysis group (n=18) no significant difference in treatment status of ibuprofen vs. placebo was seen, however there was a statistically and clinically significant decrease in pain in both groups. Two potential confounding factors may have affected the trial’s results: administration of standard‐of‐care IV morphine following initial triage assessment, and the inherent episodic and self‐limited nature of biliary colic.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal.

The biliary tree is a series of ductular tissues responsible for the drainage of bile produced by the liver and pancreatic secretions from the pancreas. The biliary tree is affected by a diversity of life- threatening diseases collectively called cholangiopathies. Cholangiopathies show regionalization, with some diseases such as biliary atresia predominantly targeting extrahepatic bile ducts (EHBDs) outside of the liver. Despite this, little is known on whether anatomical location within the biliary tree contributes to differences in functionality of biliary epithelium, especially in the EHBD compartment. Additionally, reports have demonstrated the possibility for in vitro culture of bile duct stem/progenitor cell organoids from both intrahepatic (IHBD) and EHBD sources. The relation of these organoid systems to each other, and to their tissue of origin, is largely unknown. In this dissertation, I address these major questions by combining transcriptional analyses and in vitro culture of human bile duct organoids derived from primary IHBD and EHBD epithelium. First, I show that in vitro organoids can be derived from four regions of the human biliary tree: gallbladder, common bile duct, pancreatic duct, and intrahepatic bile ducts. Characterization of these organoids demonstrated expression of adult stem cell (LGR5/PROM1) and ductal (KRT19/KRT7) markers suggesting these cultures contained cells with a biliary stem/progenitor phenotype. Further, I show that IHBD organoids are distinct from EHBD organoids requiring different conditions for sustained growth. Using RNA-Sequencing, I demonstrate that primary tissues from different regions of the extrahepatic biliary tree display unique expression profiles and identify novel tissue-specific markers. I also show that only a limited number of these tissue specific differences are maintained in the in vitro organoids and that the organoids are very different from their tissue of origin. Finally, I demonstrate that IHBD, but not EHBD organoids, express a low-level of hepatocyte-specific markers under differentiation conditions. Taken together, the work in this dissertation has uncovered regional specific markers for different anatomical regions of the human biliary tree. Further, I demonstrate that major differences exist between IHBD organoids and EHBD organoids in vitro and discover that only IHBD organoids have the capacity to express hepatocyte markers under differentiation conditions. Ultimately, these results may help to identify new targets for therapeutic development for cholangiopathies and regenerative medicine. They have also provided important insight to the understanding of both basic biliary physiology and also the field of biliary stem/progenitor cell organoids.