Adenocarcinoma of the Gallbladder Incidentally Discovered in a Case of Acute Cholangitis: A Case Report

Biliary stenting in the management of large or multiple common bile duct stones

To evaluate the causes of acute cholangitis without biliary dilatation and to compare the clinical characteristics and the imaging findings between patients with acute cholangitis with and without biliary dilatation. 93 patients diagnosed with acute cholangitis underwent contrast-enhanced CT. Among them, 17 patients were classified as not having biliary dilatation (Group 1) and 76 patients were classified as having biliary dilatation (Group 2). The causes of acute cholangitis were evaluated in both groups. Clinical characteristics and imaging findings were compared between the two groups. The causes of acute cholangitis without biliary dilatation included common bile duct (CBD) stones (n=11), CBD sludge (n=3), a passed stone (n=1) and unknown causes (n=2). The total bilirubin levels of Group 1 were significantly lower than those of Group 2 (p=0.001). By contrast, Group 1 had higher median alanine aminotransferase (ALT) levels than Group 2 (p=0.04). The length of hospital stay was significantly longer in Group 2 than in Group 1 patients (p<0.001). In the imaging findings, the extent of transient hepatic attenuation differences (THADs) (p=0.003) were significantly smaller in Group 1 than in Group 2. CBD stones and sludge were the most common causes of acute cholangitis in patients without biliary dilatation. These patients showed lower levels of bilirubin and higher levels of ALT than those with acute cholangitis with biliary dilatation, and had a shorter duration of hospital stay. The extent of THADs was the only discriminative CT finding between the two groups. Acute cholangitis can present without biliary dilatation on imaging, and the most common causes are CBD stones and sludge. The patients with acute cholangitis without biliary dilatation have different clinical characteristics and imaging findings compared with those with acute cholangitis presenting with biliary dilatation.

Older patients with simultaneous main bile duct and gallbladder stones, especially those with high-surgical risks, create a common clinical dilemma. After successful endoscopic removal of main bile duct stones, should these patients undergo laparoscopic cholecystectomy to reduce risk of recurrent biliary events? In this population-based cohort study, we report long-term outcomes of a wait-and-see strategy after successful endoscopic extraction of main bile duct stones. Consecutive patients 75 years or older undergoing endoscopic stone extraction without subsequent cholecystectomy in two tertiary academic centers between January 2010 and December 2018 were included. Primary outcome measure was recurrence of biliary events. Secondary outcome measures were operation-related morbidity and mortality. A total of 450 patients (median age, 85 years; 61% female) were included, with a median follow-up time of 36 months (0-120 months). Recurrent biliary events occurred in 51 patients (11%), with a median time from index hospital admission to recurrence of 307 days (12-1993 days). The most common biliary event was acute cholecystitis (7.1%). Twelve patients had cholangitis (2.7%) and two biliary pancreatitis (0.4%). Only one patient (0.4%) underwent surgery due to later gallstone-related symptoms. Eighteen patients (4.0%) required endoscopic intervention and 16 (3.5%) underwent surgery. There were no operation-associated deaths or morbidity among those undergoing later surgical or endoscopic interventions. In elderly patients, it is relatively safe to leave gallbladder in situ after successful sphincterotomy and endoscopic common bile duct stone removal. In elderly and frail patients, a wait-and-see strategy without routine cholecystectomy rarely leads to clinically significant consequences. Therapeutic/Care Management; Level III.

Acute biliary pancreatitis: when should the endoscopist intervene?

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Invisible or negligent—<scp>EUS</scp> detection for the negative <scp>CT</scp> or/and <scp>MRCP CBD</scp> stone

The role of endoscopy in the management of choledocholithiasis

Therapeutic role of ERCP in the management of suspected common bile duct stones.

Cholelithiasis, or gallstone(s), is a leading cause of healthcare utilization in the United States. It is more common in adults but can occur in the pediatric population as well. The following is a case report of choledocholithiasis in a 19-month-old girl.A 19-month-old girl with abdominal pain presented to the emergency department (ED) after being found to have cholelithiasis on an outpatient abdominal ultrasound (US). Three days prior to presentation, the patient was seen by her pediatrician for fussiness, decreased oral intake, and non-bloody, non-bilious emesis. She was diagnosed with a suspected urinary tract infection (UTI) and prescribed amoxicillin-clavulanate for empiric treatment. The following day, the patient returned to her pediatrician for worsening abdominal pain; she was given one dose of intramuscular ceftriaxone and scheduled for outpatient abdominal US.Her past medical history is significant for omphalocele status post-surgical correction, several congenital cardiac defects, bilateral small kidneys, and poor weight gain. The patient has a normal chromosomal microarray and no family history of hepatobiliary/pancreatic disease.In the ED, the patient was afebrile and hemodynamically stable. Physical examination was significant for mild hepatomegaly, mild abdominal tenderness without peritoneal signs, and the presence of a well-healed surgical scar on the abdomen with an underlying abdominal hernia. Laboratory tests were significant for leukocytosis of 14.5×103/microliter (mcL), elevated gamma-glutamyl transferase (GGT) of 305 unit/L (U/L), aspartate aminotransferase (AST) of 86 U/L, alanine aminotransferase (ALT) of 343 U/L, total bilirubin of 2.3 milligram/deciliter (mg/dL), direct bilirubin of 1.6 mg/dL, and lipase of 1,726 U/L. Abdominal US revealed several gallstones and mild to moderate intra- and extrahepatic biliary ductal dilatation likely due to a stone in the distal common bile duct (CBD). Pediatric surgery and gastroenterology recommended admission for pain management and magnetic resonance cholangiopancreatography (MRCP).After admission, the patient was started on ursodiol and piperacillin/tazobactam. MRCP showed a common hepatic duct measuring 13 mm and a 9×5 mm stone in the distal common bile duct. Due to a lack of available outside facilities with the capability to perform endoscopic retrograde cholangiopancreatography (ERCP) in a pediatric patient, medical management was pursued. Throughout her admission, the patient improved clinically, laboratory studies became normal, and pain was controlled. Repeat US showed persistent biliary dilation with cholelithiasis. The patient was cleared for discharge on ursodiol and amoxicillin-clavulanate and close follow-up with pediatrician, pediatric surgeon, and pediatric gastroenterologist.Follow-up US performed two weeks after discharge showed interval resolution of intra- and extrahepatic biliary duct dilatation and cholelithiasis without evidence of cholecystitis.Abdominal pain accounts for 5%-10% of all pediatric ED visits, and although cholelithiasis and choledocholithiasis are rare in the pediatric population, as this case demonstrates, it is an important differential diagnosis. Observation is the recommended management for asymptomatic patients as most cases spontaneously resolve. Patients with clinical signs or laboratory abnormalities can be treated medically, with ERCP, or with cholecystectomy.

Cholecystectomy Reduces Recurrent Pancreatitis and Improves Survival After Endoscopic Sphincterotomy

Primary closure after laparoscopic common bile duct exploration is feasible for elderly patients: 5-Year experience at a single institution

Although the standard treatment of gall bladder and bile duct stones has been surgical, postoperative morbidity and mortality increase with age and concomitant disease.1 Peroral endoscopic techniques provide an effective...

Background: Common bile duct (CBD) stone is a relatively frequent disorder in our clinical practice. Early diagnosis and prompt treatment are the most important for managing CBD stones. The various modalities of treatments in bile duct stones include open, endoscopic, and laparoscopic approaches. Aim and Objectives: CBD stones are one of the common diseases faced by both surgeons and gastroenterologists. Many patients remain asymptomatic and show mild-to-moderate dyspeptic symptoms. However, symptomatic patients are frequently associated with complications that cause a lot of suffering to the patients. At present, open, endoscopic, and laparoscopic approaches are available for the management of bile duct stones with surgical methods slowly giving a way to other two newer modalities. However, treatment modalities should be individualized. The objectives of the study are various modalities of treatments in bile duct stones and the efficacy of these modalities in terms of outcomes, morbidity, and mortality. Materials and Methods: This was a prospective study of 68 patients who were admitted to Peerless Hospital and B.K. Roy Research Center between October 2014 and December 2015. Results: In this study, CBD stones were common in females between 55 and 64 years of age group. The presentation of the disease ranged from asymptomatic to symptomatic with features of complications in the form of acute biliary pancreatitis and cholangitis. Pain was the leading symptom, followed by jaundice and fever. Transabdominal USG revealed stones in bile ducts in 41.2% of cases, and the diagnosis was suspected in 26.4% of cases by only seeing proximal dilated bile ducts. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) stone extraction procedure, and in cases where the endoscopic procedure failed, open CBD exploration was done. The success rate of open surgery is marginally high than that of endoscopic intervention. Choledochoduodenostomy was performed in one patient where the open procedure failed to extract all the stones from the bile ducts. Complications seen in ERCP are pancreatitis (4.4%), hemorrhage (2.9%), cholangitis (1.5%), and death in 1 (1.5%) patient, following a severe attack of pancreatitis. Conclusion: From the above study, it is clear that open surgery is more successful than endoscopic procedure. ERCP failed due to multiple large stones and its impaction at the lower end of CBD. Hence, the patients should be categorized properly after a pre-operative workup. Facilities for the procedure and availability of experienced doctors are also crucial in making the decision.

Bile duct stones, indeterminate biliary strictures and other biliary duct pathologies represent a significant surgical and endoscopic challenge in patients with altered luminal or biliary anatomy. Traditional endoscopic retrograde cholangiopancreatography (ERCP) is not feasible and alternative approach is usually required. A novel alternative approach of addressing these challenging cases is assessed by this case series. All patients who underwent percutaneous transhepatic cholangioscopy (PTCS) and SpyglassTM Direct visualization system (SDVS) between December 2016 and February 2018 were studied. The indications for procedure, interventions performed, outcomes and complications were reviewed for each case. SpyglassTM marketed by Boston Scientific Corporation, Marlborough, Massachusetts was utilized by interventional endoscopists and radiologists through a 12 French (Fr) percutaneous vascular sheath. Five patients had altered biliary and/or luminal anatomy: two with Roux-en-Y gastric bypass and three with Roux-en-Y hepaticojejunostomy. All patients had unsuccessful previous ERCP attempts. All PTCS with SDVS procedures were technically successful. Indications for this unusual approach were: ascending cholangitis, abnormal liver function tests and biliary dilation on imaging. SDVS was utilized to conduct electrohydraulic lithotripsy (EHL) for biliary stone management in four patients and intraductal biopsies for indeterminate strictures in two of them. PTCS with SDVS can be beneficial for multiple diagnostic and therapeutic indications in patients with altered biliary or luminal anatomy. SDVS allows direct evaluation and management of different biliary pathologies in challenging cases where traditional ERCP is not feasible. Some indications for PTCS with SDVS include evaluation of biliary strictures and biliary stasis, biliary tract biopsy and lithotripsy for management of biliary stones.

Is your sphincterotomy really safe—and necessary?