Biliary Tract Dilatation Research Articles

Gallbladder dysfunction caused by MYPT1 ablation triggers cholestasis-induced hepatic fibrosis in mice.

The incidence of gallbladder diseases is as high as 20%, but whether gallbladder diseases contribute to hepatic disorders remains unknown. Here, we established an animal model of gallbladder dysfunction and assessed the role of a diseased gallbladder in cholestasis-induced hepatic fibrosis (CIHF). Mice with smooth muscle-specific deletion of Mypt1, the gene encoding the main regulatory subunit of myosin light chain phosphatase (myosin phosphatase target subunit 1 [MYPT1]), had apparent dysfunction of gallbladder motility. This dysfunction was evidenced by abnormal contractile responses, namely, inhibited cholecystokinin 8-mediated contraction and nitric oxide-resistant relaxation. As a consequence, the gallbladder displayed impaired bile filling and biliary tract dilation comparable to the alterations in CIHF. Interestingly, the mutant animals also displayed CIHF features, including necrotic loci by the age of 1 month and subsequently exhibited progressive fibrosis and hyperplastic/dilated bile ducts. This pathological progression was similar to the phenotypes of the animal model with bile duct ligation and patients with CIHF. The characteristic biomarker of CIHF, serum alkaline phosphatase activity, was also elevated in the mice. Moreover, we observed that the myosin phosphatase target subunit 1 protein level was able to be regulated by several reagents, including lipopolysaccharide, exemplifying the risk factors for gallbladder dysfunction and hence CIHF. We propose that gallbladder dysfunction caused by myosin phosphatase target subunit 1 ablation is sufficient to induce CIHF in mice, resulting in impairment of the bile transport system.

A rare variation of common hepatic artery identified during pancreaticoduodenectomy: a case report and literature review from Syria

Introduction: It is common for the liver to be supplied blood by a hepatic artery branching off the coeliac trunk. Occasionally, a replaced common hepatic artery (RCHA), emerges from the superior mesenteric artery (SMA), can supply the liver in 1.5–4.0% of cases. Computed tomography (CT) angiography is a highly accurate method for identifying arterial anomalies, which may remain undetected until the time of surgery, leading to unexpected complications. Case presentation: A 53-year-old male exhibiting symptoms of decreased appetite, weight loss, vomiting, and altered sclera, urine, and stool colour, underwent a contrast-enhanced CT scan revealing biliary tract dilatation and pancreatic abnormalities, leading to a pancreaticoduodenectomy. During the surgery, an uncommon arterial finding—CHA from SMA—was noted. Pancreatic cancer was confirmed. The patient was discharged a week post-surgery without issues, emphasizing perioperative care progress. Discussion: The authors’ study focused on the detection conditions of the same hepatic artery anomaly in eight cases reported between 2017 and 2023. In two of them the anomaly was discovered in cadaver by routine autopsy. In three cases, this variation was identified before the surgery, but in three other cases it wasn’t detected until the surgical procedure. In the authors’ case, due to multiple reasons, the anomaly remained undetectable until the surgery. Conclusion: This study underscores the importance of thorough preoperative evaluation to grasp vascular variations for better patient care. Also, a noteworthy observation in our case is that the surgeon identified an expanded hepatic vessel, prompting further investigation into this anomaly.

Biliary Tract Disorders and Associated Acute Complications in Patients With Acromegaly: A Single-Center Study.

Biliary complications are frequent in patients with acromegaly. These complications may be secondary either to acromegaly or to somatostatin analogs (SAs). We aimed in this paper to assess the prevalence of biliary complications in patients with acromegaly at diagnosis and after treatment with SAs. We conducted an analytical and descriptive retrospective study of 26 patients followed up for acromegaly over 7 years. Biliary complications were screened at diagnosis and follow-up by abdominal ultrasound, biliary magnetic resonance imaging (MRI), and endoscopic ultrasonography (EUS). Data were analyzed using SPSS 21. The mean age of the patients was 49.6 ± 14 years, with a female predominance (53.8%). The evaluation of biliary complications showed vesicular biliary tract lithiasis and/or sludge in seven patients (29%), including two patients at the time of diagnosis of acromegaly and five patients after an average medical treatment duration of 3 years. Six female patients (24%) had dilation of the bile ducts without the presence of obstruction on biliary MRI and EUS and lithiasis/sludge of the common bile duct, tumor or external compression have been excluded. This condition was discovered incidentally at the diagnosis in five patients and during the follow-up in one patient. The preoperative insulin-like growth factor 1 (IGF-1) levels, disease duration, and female sex were significantly correlated with biliary tract dilation occurrence. Dyslipidemia, the preoperative IGF-1 level, and lanreotide treatment duration were significantly correlated with the occurrence of biliary lithiasis (P < 0.05). Biliary stones are a frequent biliary adverse effect in patients with acromegaly undergoing SAs treatment. However, primary bile duct dilation has never been reported in acromegaly to the best of our knowledge. This condition could be considered as a complication or a feature of the disease.

Atypical localization of metastatic melanoma in the gastrointestinal tract.

Although most melanomas are diagnosed in early stages of the disease, a significant percentage show metastases from the beginning or during follow-up. The most common route is lymphatic, while hematogenous spread is less frequent. The most common site for metastases is the skin itself, although they can also occur in other organs, including the digestive tract, where the small intestine is the most frequently affected organ (2). We present the case of a 48-year-old woman with a history of superficial spreading melanoma of the cervical region, surgically treated 7 years prior and in remission, who presented with painless jaundice of 48 hours duration, without fever or other infectious focus. Upon arrival at the Emergency Department, she had a direct bilirubin of 7.9 mg/dL and a CRP of 140 mg/L. An abdominal ultrasound was performed, revealing biliary tract dilation without apparent cause, with secondary, apparently tumoral involvement of the gallbladder. During hospitalization, the study was completed with an abdominal CT scan, visualizing hyperdense lesions with a polypoid appearance in the gallbladder, in addition to the aforementioned intra- and extrahepatic biliary tract dilation. The cause was then identified as a hyperdense mass in the duodenum affecting the papilla, along with two other small hypervascular polypoid lesions in the second portion of the duodenum. With these findings, an ERCP was performed, revealing a papilla with a "pregnant" appearance, compatible with ampulloma, in addition to duodenal pseudopolyps of nonspecific appearance. The anatomopathological analysis was compatible with duodenal metastases from melanoma. Melanoma is the cancer with the highest mortality rate, and the gastrointestinal tract is a typical location for metastases, only surpassed by the skin itself and the lungs, especially the small intestine, although not the duodenum, where they are found in only 12% of cases (4). In this case, the diagnosis was complicated by the endoscopic appearance of the lesion, as the characteristic features are pigmented, blackish lesions typical of melanoma. As seen in the image, these lesions had an erythematous and pseudo-inflammatory appearance, so for diagnosis and treatment, it was essential to consider the history of the disease to perform an adequate anatomopathological diagnosis.

Study of Intrahepatic Biliary Architecture in Patients Operated for Extrahepatic Biliary Atresia using Magnetic Resonance Cholangiopancreatography.

The aim is to study intrahepatic biliary architecture in patients following Kasai's portoenterostomy for extrahepatic biliary atresia using magnetic resonance cholangiopancreatography (MRCP). It is a prospective observational study in a cohort of patients who have survived with a complete jaundice-free period for at least 1 year. MRCP was done to look for various intrahepatic architectural changes during their last visit. Findings were correlated with liver functions and growth and development. Twenty-one patients were included in the study. The male-to-female sex ratio was 1.6:1, the median age at surgery was 75 days (18-140 days), and the median age at magnetic resonance imaging (MRI) was 4 years (18 months-18 years). More than 2 years of follow-up was in seven patients. Left lobe hypertrophy was observed in six patients, right lobe hypertrophy was in three patients, intrahepatic biliary tract dilatation was in five patients, and altered signal intensity between intrahepatic ducts was seen in five patients. In addition, hypointense foci in the spleen were seen in one patient. Twelve children had normal weight for their age, ten children had the normal height for their age, and gamma-glutamyl transferase was elevated in all children. Only four children had a history of fever and jaundice. The patients who survive after successful surgical intervention have near-normal liver gross architecture as on MRI/MRCP. Occasional findings of dilatation and lobar atrophy/hypertrophy are possible, especially in those with a history of cholangitis. The survivors also have acceptable growth parameters and normal liver functions.

Nivolumab treatment in a patient with BRAF mutant advanced melanoma and liver failure with encephalopathy.

We report the case of a patient with melanoma and liver failure with encephalopathy, successfully treated with nivolumab without major side effects and encouraging prolonged disease control. In June 2022, metastatic lesions appeared in the liver associated with melanoma progression under treatment. Liver biopsy was non-diagnostic. The patient developed fever, abdominal distension, and jaundice. Liver function tests (LFTs) began to deteriorate. Hepatic encephalopathy developed in accordance with the worsening liver functions in the patient. Upper abdominal MRI with primovist showed multiple, progressive, metastatic lesions in the liver and mild to moderate dilatation of the intrahepatic biliary tract. Patient was evaluated as acute cholangitis associated with the compression of the biliary tract by progressive liver metastases. In December 2022, the patient was started antibiotherapy for cholangitis and Nivolumab (240 mg flat dose, every 2 weeks) therapy. After the first dose, both LFT and constitutional symptoms began to improve. Subsequently, LFTs almost completely returned to normal, clinical response was achieved. Multiple metastatic lesions in the liver regressed in the radiological evaluation performed at the third month of nivolumab treatment. With partial response, nivolumab treatment is continued. In this case is reported patient with hepatic encephalopathy due to an advanced refractory melanome successfully, and safely, treated with programed cell death-1 (PD-1) inhibitors. Clinical trials to explore the benefits of these immunotherapies in the hepatic failure population with advanced solid tumors should be supported.

Clinical and genotypic analysis of hereditary spherocytosis combined with cholestasis among pediatric patients

Objective: To understand the clinical and genetic characteristics of hereditary spherocytosis (HS) combined with cholestasis among pediatric patients. Methods: 12 cases of HS children accompanied by cholestasis at Hunan Children's Hospital were selected as the research subjects between January 2013 and December 2022. Clinical data were collected. Whole-exome sequencing was performed by second-generation sequencing. Suspected pathogenic mutation sites were verified by Sanger sequencing. Results: All pediatric patients were admitted to the hospital due to their yellow skin tone. Eight cases (66.67%) had a positive family history. The clinical manifestations were jaundice, splenomegaly (12/12), abdominal pain, anemia (4/12), and hepatomegaly (5/12). All pediatric patients had decreased hemoglobin, an increased reticulocyte ratio, total bilirubin and direct bilirubin, a positive erythrocyte fragility test, and remarkable spherical erythrocytes in their peripheral blood. Seven cases had elevated aminotransferase; four cases had severely elevated aminotransferase and bilirubin; eight cases had biliary calculi; and two cases had a dilated biliary tract. Liver pathological examination showed mild damage to the liver cells (G1S1) in three pediatric cases. Five children had a total of six unreported mutations: SPTB gene c.2431_2450del, c.4974-2A > G, c.2575G > A, and exon 22-35 deletion; ANK1 gene: c.2379-2380delC; and c .6dupC. Children still had abnormal bilirubin levels following treatment. Two pediatric cases underwent splenectomy. Bilirubin and hemoglobin levels returned to normal after surgery. Conclusion: Children with HS may experience cholestasis, and those with poor treatment results may consider undergoing a splenectomy. Six new types of variants have expanded the HS gene mutation spectrum.

Effectiveness of ultrasound screening in right upper quadrant pain: A comparative study in a basic emergency service.

The use of ultrasound screening is primarily facilitated by point-of-care ultrasound (POCUS) and its integration into healthcare systems is a result of the versatility of this imaging technique. This study intends to compare the accuracy and pertinence of sonographic findings obtained by a sonographer in a Basic Emergency Service (BES) with that of radiologists at referral hospital (RH) in Portugal. Twenty patients with right upper quadrant (RUQ) pain and suspected cholecystitis or biliary pathology underwent sonography screening using POCUS in the BES. They were then forwarded to the RH where a radiologist performed a conventional ultrasound exam on the same patients. The results of both exams were compared to determine if the findings obtained in the BES were confirmed by the radiologist in the RH. In our sample, 60% of cases were related to biliary pathology, 20% were liver-related, 10% had hepatopancreatic biliary etiology, and 10% had unknown etiology. A strong association between the sonographic findings in the BES and the RH was found in the variables "Sonographic Murphy sign" (V = 0.859; p = 0.001), "Cholelithiasis/Gallbladder sludge" (V = 0.840; p = 0.001), and "Intrahepatic biliary tract dilatation" (V = 0.717; p = 0.006). Adequate measures of agreement between the findings of the radiographer and radiologist were obtained for the "Sonographic Murphy sign" (k = 0.664; p = 0.001) and the presence of "Cholelithiasis/Gallbladder sludge" (k = 0.712; p = 0.000). Major biliary abnormalities were detected in patients with RUQ pain in BES using sonography. The correlation between the sonographic findings obtained by the sonographers at BES and those obtained by radiologists at the RH in Portugal was strong, showing that POCUS screening could be extended to other similar settings; however, more studies are needed.

Double common bile duct with cholelithiasis.

Double common bile duct is a rare congenital anomaly among biliary anomalies. The anomaly has an important clinical implication because of its association with biliary tract obstruction. In addition, if one of the two common bile ducts is mistaken for the cystic duct during surgery, residual stones and bile duct injury are likely to occur. Here, we report a case of double choledochal variation (Type Vb) with choledochal calculi. An 82-year-old woman was admitted to the hospital due to mild pain in the upper abdomen accompanied by vomiting for 3 days. Magnetic resonance imaging suggested common bile duct lithiasis, variation of the common bile duct and moderate biliary tract dilation. Laparoscopy combined with choledochoscopic lithotomy was performed for choledocholithotomy. During the operation, left and right choledocholithotomy was performed, and all the gallstones were removed via choledochoscope. The patient's post-operative recovery was good, and no recurrence of cholelith had been observed at the time of writing.

Research application of endoscopic ultrasound - fine needle aspiration in diagnosis pancreas tumors

Background: Pancreatic diseases is very multiform and complex, in which pancreatic tumors have often poor prognosis, especially pancreatic cancer. Early detection and diagnosis of pancreatic tumors have great significance in improving the quality of treatment and prognosis for patients. Endoscopic ultrasound has the advantage of high-frequency ultrasound, an optimal approach to provide a possibility of EUS-FNA. This is important evidence to confirm the diagnosis, guide to treatment and prognosis. This study was aimed at: (1) To describe the characteristics of the pancreatic tumor by endoscopic ultrasound; (2) To evaluate the efficacy and safety of endoscopic ultrasound fine needle aspiration in the diagnosis of pancreatic tumors. Subject and methods: Cross-sectional study concludes 41 pancreatic tumor patients, which indicated endoscopic ultrasound fine needle aspiration in Gastroenterology - Endoscopy Center, Hue University of Medicine and Pharmacy Hospital from 2/2010 to 10/2022. Results: The size of the tumor was more than 2cm, tumors in the pancreatic head accounted for 80.5% and solid tumors accounted for 80.5%. Besides, the main pancreatic duct dilatation accounts for 39.0%, the biliary tract dilatation accounts for 46.3%, pancreatic tumor invades adjacent organs accounts for 29.3%, vascular invasion accounts for 24.4%, with lymph nodes accounting for 51.2%. Endoscopic ultrasound-guide fine needle aspiration pancreatic tumor was performed in 37/41 cases (90.3%). Pathological of pancreatic tumor: pancreatic cancer is highest about 59.5%, benign pancreatic tumors accounted for 10.8%, mucinous cysts accounted for 5.4% and pancreatic tuberculosis accounted for 2.7%. The complication rate of the procedure was 5.4%. Conclusion: Endoscopic ultrasound fine needle aspiration pancreatic tumors showed relative safety and efficacy, the technical failure rate is very low Key words: Pancreatic tumor, Endoscopic ultrasound fine needle aspiration

Interstitial Lung Disease, Intestinal Pseudo-obstruction, Biliary Tract Dilatation in a Patient with Sjogren's Syndrome.

Interstitial Lung Disease, Intestinal Pseudo-obstruction, Biliary Tract Dilatation in a Patient with Sjogren's Syndrome.

Endoscopic ultrasound in diagnosis and management of some gastrointestinal - pancreaticobiliary diseases at Hue University of Medicine and Pharmacy Hospital

Background: Gastrointestinal - pancreaticobiliary diseases is a major pathology relating to organs from the mouth to the anus and biliary tree. Endoscopic ultrasound (EUS) helps to assess deeper organs in the abdomen such as pancreas, biliary tree, lesions inside and outside the alimentary tract as well as regional lymph nodes. We proceeded this study to: (1) To examine some characteristics of patients, indications and safety of EUS, (2) To evaluate roles of EUS in diagnosis and management of gastrointestinal - pancreaticobiliary diseases. Materials and method: A cross-sectional study was conducted on 1615 patients undergoing endoscopic ultrasound at Hue University of Medicine and Pharmacy Hospital. Results: Male:female ratio = 1.4:1. Average age was 56.1 ± 15.1. Patients living in Hue was 79.9%, not living in Hue was 20.1%. Indications of EUS: in biliary diseases 37.1%, in pancreatic diseases 31.3%, in stomach 11.8%, in colon 9.0%, in esophagus 8.6%, and in duodenum 2.2%. Complications rates were very low. Lesions in gastrointestinal tract: Subepithelial lesions in stomach 57.9%, in esophagus 23.7%, in duodenum 13.6%, in colo-rectum 4.8%; cancer in colo-rectum 48.8%, in esophagus 33.2%, in stomach 16.3%, and in duodenum 1.7%. Lesions in biliary tree: gallstones 76%, common bile duct cyst 9.5%, bile duct parasitic lesions 4.3%, Vater tumor 3.8%, unknown causes biliary tract dilation 3.4% and cholangiocarcinoma 3.0%. Lesions in pancreas: chronic pancreatitis40.6%, pancreatic cancer 24.6%, acute pancreatitis 18.4%, pancreatic cyst 10.9% and lymph nodes 5.5%. EUSfine needle aspiration and EUS-guided drainage of pancreatic pseudocysts: FNA for 18 pancreatic tumors, 3 pancreatic cysts and 7 lymph nodes; drainage for 4 pancreatic pseudocysts. Conclusions: Diagnostic and interventional EUS were effectively and relatively safe in assessing lesions in alimentary tract and biliary diseases, as well as supporting to achieve samples through fine needle aspiration, and to drain pancreatic pseudocysts. Key words: endoscopy, endosonography

Todani type III: like biliary dilatation with duodenal prolapse—a case report

BackgroundBiliary dilatation is a rare disease involving intrahepatic and extrahepatic biliary tract abnormalities. With the development of imaging technology, an increasing number of special cases have been diagnosed, which poses a challenge to the traditional classification method.Case presentationA 50-year-old woman was admitted to the hospital due to right upper quadrant pain for more than 10 days. The patient had previous episodes of similar symptoms, which were relieved after symptomatic treatment at a local community hospital. After the symptoms developed, she underwent a computed tomography scan at the local hospital, which showed biliary dilatation; thus, she was referred to our hospital for further treatment. After admission, her magnetic resonance imaging examination also suggested biliary dilatation, but abnormal signals were found in her duodenum. First, a duodenal diverticulum was considered. Later, endoscopic ultrasonography was conducted, and the results suggested that the dilated biliary tract had herniated into the duodenum. This type of lesion is most closely classified as a Todani type III lesion. The patient finally underwent choledochectomy and Roux‑en‑Y hepaticojejunostomy, and the postoperative pathology was consistent with our preoperative diagnosis. The patient was followed up for approximately 2 years, and no obvious postoperative complications were found.ConclusionsThe manifestations of this case are relatively rare and involve one of the undiscussed categories of the Todani classification system; therefore, this case has certain clinical value. Moreover, there is no report similar to this experience in the previous literature.

Risk factors determining bile leakage after multiple liver hydatid cyst surgery

Background/Aim: Biliary leaks are the main source of morbidity after liver hydatid cyst surgery. Many identified factors have been examined in predicting biliary leaks. The aim of this study was to determine the postoperative bile leakage rate and predictive factors affecting bile leakage in multiple liver hydatid cysts. Method: In our retrospective cohort study, the data of 130 patients who underwent multiple liver hydatid surgery in our clinic between January 2007 and November 2013 were analyzed. Results: In the 130 patients with multiple cysts, 323 hydatid cysts were detected. The number of cysts was 2 in 65.4% of the patients, and 3 or more in 34.6% of the patients. The postoperative bile leakage rate was 19.2%. According to the univariate analyses, during the preoperative period, the presence of jaundice, fever, leukocytosis, eosinophilia, aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transferase, alkaline phosphatase, and direct bilirubin increase, the largest cyst being located in the perihilar region, the mean diameter of the cyst, the diameter of the largest cyst, biliary tract dilatation on the preoperative images, and infection were associated with increased postoperative bile leakage. In the multivariate analyses, eosinophilia and biliary tract dilatation on the preoperative images were found to be independent risk factors for postoperative bile leakage. Conclusion: In this study, the most determining factors for bile leakage after multiple liver hydatid cyst surgery were a high eosinophil rate and the presence of dilatation in the biliary tract on the preoperative radiological images.

Systemic lupus erythematosus simultaneously presenting with visceral muscle dysmotility syndrome and mechanical intestinal obstruction clinically relieved by surgery: a case report and literature review

BackgroundIntestinal pseudo-obstruction (IPO) accompanied by hepatobiliary dilatation and ureterohydronephrosis is extremely rare in systemic lupus erythematosus (SLE). This triad is also called visceral muscle dysmotility syndrome (VMDS). Only 9 cases have been reported in the literature. Here, we report a rare case of VMDS with mechanical intestinal obstruction that was clinically relieved by surgery.Case presentationThis report refers to a 31-year-old woman with SLE and gastrointestinal symptoms presented as abdominal pain, nausea and stoppage of the passage of flatus or stool without obvious reasons. The patient suffered from severe abdominal distension because of massive flatulence. Contrast-enhanced computed tomography (CT) of the abdomen performed in our hospital showed localized stenosis of the bowel, ureterohydronephrosis, and biliary tract dilatation. Endoscopy showed a stenotic segment located in the sigmoid colon. The colon biopsy samples suggested that the stenosis was caused by inflammatory tissues. Biochemical investigations showed hypoalbuminemia, electrolyte disturbance and decreased C3. Antinuclear antibody was positive. After careful assessment, transverse colostomy was performed for this patient. Gastrointestinal symptoms were clinically relieved after the surgery.ConclusionTo the best of our knowledge, no VMDS patients have presented with mechanical ileus before. This case is the first documented occurrence of SLE with VMDS and mechanical intestinal obstruction symptoms relieved by surgery. Due to the low incidence of this condition, no standard treatment regimen has been established. However, surgical treatment offers significant benefit in specific situations.

Radiological evaluation of response to treatment in hepatobiliary fascioliasis

PurposeIn this study, we aimed to evaluate the computed tomography (CT) findings of Fasciola hepatica infestations on initial and follow-up imagings after treatment, and also to describe the role of CT during diagnosis. MethodsIn this retrospective study, patients with a diagnosis of fascioliasis by clinical and laboratory examination who underwent initial and follow-up contrast-enhanced abdominal CT scans after treatment (a single oral dose of 10mg/kg Triclabendazole) were included. The CT scans were evaluated regarding liver and spleen sizes, portal and splenic vein diameters, involved hepatic segment numbers and involvement patterns, the presence of focal perihepatic hyperdensity, gallbladder wall thickening, dilatation of the intrahepatic biliary tract, periportal-right subdiaphragmatic lymphadenopathy, hepatic subcapsular and intra-abdominal bleeding, and perihepatic/intraabdominal free fluid. Initial (pre-treatment) and post-treatment CT scans (average 25 months after the treatment) were compared with for these features. ResultsA total of 36 patients with a mean age of 39.28±14.64 [15-83] years, were included in this study. After treatment, marked improvement in liver parenchymal involvement, biliary system findings, hepatomegaly-splenomegaly, periportal-peridiaphragmatic lymphadenopathy, and hepatic subcapsular hematoma were detected and focal perihepatic hyperdensity, free intraperitoneal fluid disappeared. ConclusionContrast-enhanced abdominal CT can be used in the diagnosis and post-treatment follow-up of fascioliasis. Awareness of intrahepatic/extrahepatic lesions and all the complications of fascioliasis can greatly aid the diagnosis and also evaluation of the response to treatment.

S2761 Recurrent Oriental Cholangiohepatitis Despite Partial Hepatic Resection

Introduction: Recurrent pyogenic cholangiohepatitis (RPC), also known as “Oriental Cholangiohepatitis”, is commonly found in people of Southeast Asian origin. RPC is characterized by recurrent cholangitis secondary to bile stasis and stone formation proximal to biliary strictures. We present a case of recurrent pyogenic cholangiohepatitis with hepatic abscess in a Vietnamese male with history of partial hepatic resection. Case Description/Methods: A 42 year old Vietnamese male with a past medical history of recurrent pyogenic cholangitis and hepatolithiasis status post hepaticojejunostomy in 2009, followed by abscess resection with culture positive Klebsiella, segment 3 resection, and biliary stenting in 2013 presented with two days of RUQ pain, fevers and jaundice. On arrival, the patient was afebrile, tachycardic and mildly hypotensive. Laboratory evaluation demonstrated alkaline phosphatase 360 IU/L, total bilirubin 14.4 mg/dL, ALT 93 IU/L, AST 113 IU/L, WBC 24,000, INR 1.3. Findings on CT scan of the abdomen included 10 cm multiloculated liver abscess in segment 4A, dilated biliary tract with small pneumobilia and dense material, and a 3.9 x 2.8 cm mass-like hyperdense region in the portal triad region visualized in arterial phase. The patient was started on broad spectrum antibiotics and underwent percutaneous abscess drainage with 350 mL of purulent material removed. MRCP the following day redemonstrated a liver abscess measuring 9.5 cm, RUQ drain in place, diffuse dilatation of the intrahepatic and extrahepatic bile ducts with multiple filling defects consistent with calculi, and a 14mm common bile duct. Cultures from the abscess grew ESBL E.coli and Provotella, and the patient was transitioned to Ertapenem with plan to continue antibiotics for four weeks. The patient was discharged home with abscess drain in place. Discussion: RPC is a recurrent syndrome of cholangitis triggered by a parasitic infection which causes biliary fibrosis leading to strictures and stone formation within intrahepatic ducts, most often on the left. Treatment includes antibiotics, stricture dilation, biliary drainage, stone removal, and liver resection. Although liver resection of the segment decreases the risk of recurrent cholangitis, abscess, and eliminates the risk of carcinoma in that segment, resection does not resolve the biliary fibrosis throughout the remaining segments leaving the patient at risk for recurrence. Liver transplant can be considered for complicated cases that do not respond to conventional therapies.Figure 1.: 10 cm multiloculated liver abscess in segment 4A.

Squamous cell carcinoma arising within choledochal cyst managed by pancreaticoduodenectomy: A case report.

Introduction and importanceCholedochal cysts (CC) are rare cystic dilatation of the biliary trees. Malignancy is one of the important significant findings in CC and its incidence increases with age. Associated squamous cell carcinoma of the choledochal cyst is an uncommon pathological finding.Case presentationWe present a 21-year-old male diagnosed with type 1 CC and planned for excision of the cystic dilated extrahepatic biliary tract with hepaticojejunal anastomosis in Roux-en-Y but underwent pancreaticoduodenectomy due to intraoperative palpable mass of CC which was adhered to the duodenum and pancreatic head. Histopathology of the excised specimen revealed squamous cell carcinoma (SCC) of the choledochal cyst.DiscussionCC represents a rare biliary cystic disease. Though infrequent, malignant transformation in CC includes cholangiocarcinoma, adenocarcinoma, and rarely SCC. The post-operative management for SCC in CC is ill-defined and carries a grave prognosis.ConclusionThe choledochal cyst should be completely excised wherever possible to avoid the possible malignant transformation in CC including SCC.

Early Intervention and Resolution of Pediatric Intestinal Pseudo-Obstruction in Systemic Lupus Erythematosus: A Pediatric Case Report

Early Intervention and Resolution of Pediatric Intestinal Pseudo-Obstruction in Systemic Lupus Erythematosus: A Pediatric Case Report

DOES AGE INFLUENCE IN ENDOSCOPIC THERAPEUTIC SUCCESS ON THE BILIARY TRACT?

ABSTRACT Background:Retrograde endoscopic cholangiopancreatography (ERCP) effectively treats biliary and pancreatic disorders. Its indications are limited and precise, since its misuse delays adequate treatment, increases costs and to patient´s adverse events. Aim:To compare clinical, radiological and exploratory characteristics in relation to therapeutic success in patients undergoing ERCP in relation to age. Method:421 patients who underwent the method were retrospectively studied; those who were not able to access the duodenal papilla were excluded. The patients were divided into two age groups: <60 years (group 1) and >60 years (group 2), and the variables of gender, examination indications, radiological findings, therapeutic success, diagnosis and the occurrence of immediate adverse events were analyzed. Results:177 patients were allocated to group 1 and 235 to group 2. The main indication found in both groups was choledocholithiasis. In group 2, the number of cases of acute cholangitis (p=0.001), biliary stenosis (p=0.002) and papilla cancer (p=0.046) was higher. In this group, urgent indication for ERCP was higher (p=0.042), as well as the diagnosis of biliary tract dilatation (p<0.001). The placement of prostheses was the most common procedure performed in both groups, but the greatest number of patients in absolute quantity occurred in group 2. In group 1, the success in catheterization and the chance of achieving clearing of the biliary tract was significantly higher in compared to group 2 (p=0.016, OR=2.1). Conclusion:The success of catheterization and complete clearance of the bile duct was significantly higher in the group of young patients.