Biliary Tract Interventions Research Articles

Tumor in the liver: Six inflammatory pseudotumor patient

Inflammatory pseudotumor (IPT) is a rare liver disease confused with liver tumors. It is a disease that should be known in the differential diagnosis for clinicians as the correct diagnosis of IPT will prevent unnecessary surgery. Demographic datas, diagnoses and imaging modalities of six patients with radiologically and/or histopathologically diagnosed hepatic IPT between 2016 and 2023 were retrospectively analyzed. Four out of six patients were female and median age was 57.5 (47-66). C-reactive protein was higher in four patients, and carbohydrate antigen 19.9 level was higher in one patient. We used magnetic resonance imaging (MRI) for diagnosis in five patients. Only in one patient computed tomography was enough for diagnosis. Tumor locations were segment 5 for two patients, segment 7-8 in two patients, segment 7 in one patient, and 8 in one patient. Liver biopsy was performed in five patients because it could not be distinguished from malignancy by imaging methods. Histopathological results of all these biopsies defined as IPT. Initial tumor median size was 31 (17-55) mm. Two patients were operated on. The first one underwent right hepatectomy due to a 2-fold increase in size within 11 months. The second one had a mass indistinguishable from hepatic adenoma by MRI and underwent nonanatomic resection. In one patient, IPT disappeared completely in the 18th month of follow-up period while it regressed in size in two patients. Two of our patients had a history of recurrent endoscopic retrograde cholangiopancreatography, which we noticed incidentally before IPT was diagnosed. IPTs are liver masses with low malignant potential and may shrink spontaneously during follow-up. We suspected that biliary tract interventions may be the cause of IPT.

When the Pleural Fluid Appears in an Unexpected Color: A Bilothorax Case

Abstract Background: Bilothorax, or cholethorax, is a rare cause of exudative pleural effusion characterized by the presence of bile in the pleural space. Recognizing this condition is essential to prevent severe complications such as empyema and acute respiratory distress syndrome. Case: This report presents a 70-year-old male patient who developed right-sided bilothorax following multiple biliary tract interventions. The patient presented with symptoms of jaundice, fever, and abdominal pain. Clinical and radiological evaluations revealed right-sided pleural effusion, and thoracentesis yielded dark yellow-green fluid. The diagnosis of bilothorax was confirmed by a pleural fluid/serum total bilirubin ratio >1.0. Early intervention was performed using a cystofix to drain the pleural fluid. However, despite all interventions, the sepsis condition could not be controlled, and the patient unfortunately passed away. Discussion: Bilothorax is generally associated with hepatobiliary procedures and is mostly observed on the right side due to anatomical proximity. Diagnosis requires a high index of suspicion, especially in patients with relevant clinical histories and characteristic pleural fluid appearance. Rapid thoracentesis and pleural fluid analysis are crucial for diagnosis. Treatment typically involves pleural drainage and early administration of broad-spectrum antibiotics. Conclusion: Bilothorax is a life-threatening condition requiring urgent diagnosis and intervention. This case highlights the importance of recognizing this rare condition and the necessity for early aggressive management in patients with a history of hepatobiliary procedures.

Short-term clinical outcomes of percutaneous biliary tract interventions: analysis of success and complication rates.

Obstructive jaundice is a clinical syndrome that is commonly seen in gastroenterology. Endoscopic retrograde cholangiopancreatography (ERCP) has been recognized as a first-choice therapeutic approach, with percutaneous biliary interventions (PBIs) being a viable alternative. Recent data questions the performance and safety profile of PBIs.

Management of biliary obstruction in patients with newly diagnosed alveolar echinococcosis: a Swiss retrospective cohort study.

Alveolar echinococcosis, an orphan zoonosis affecting the liver, is of increasing concern worldwide. Most symptomatic cases present at an advanced and inoperable stage, sometimes with biliary obstruction prompting biliary tract interventions. These are, however, associated with a high risk of infectious complications. The aim of this retrospective study was to compare the effectiveness and safety of conservative and interventional treatment approaches in patients with newly diagnosed alveolar echinococcosis and biliary obstruction. Alveolar echinococcosis patients treated at two referral centres in Switzerland, presenting with hyperbilirubinaemia (total bilirubin >1.5 Upper Limit of Normal) at diagnosis were included, unless another underlying aetiology, i.e. common bile duct stones or decompensated cirrhosis, was identified. Patients were divided into two groups, according to whether they initially received a biliary tract intervention. The primary endpoint was normalisation of bilirubin levels within a 6-month period. Secondary endpoints included, among others, the occurrence of early and late biliary complications, the need for biliary tract interventions during follow-up and overall duration of hospital stays for treatment initiation and for biliary complications. 28 patients were included in this study, of whom 17 received benzimidazole therapy alone and 11 additionally received a biliary tract intervention. Baseline characteristics did not differ between groups. All but one patient in each group achieved the primary endpoint (p=0.747). Biliary tract intervention was associated with faster laboratory improvement (t1/21.3 vs 3.0 weeks), but also with more frequent early biliary complications (7/11 vs 1/17, p=0.002) and longer initial hospital stay (18 days vs 7 days, p=0.007). Biliary obstruction in patients with newly diagnosed alveolar echinococcosis can be treated effectively with benzimidazole therapy alone. Biliary tract intervention, on the other hand, is associated with a high complication rate and should probably be reserved for patients with insufficient response to benzimidazole therapy.

Extra-intestinal complications of Ascaris lumbricoides infections in India: A systematic review and meta-analysis.

The aberrant migration of Ascaris lumbricoides may cause extra-intestinal ascariasis (EIA) involving hepato-biliary-pancreatic (HBP) or other extra-gastro-intestinal (EGI) organs. We performed a systematic review and meta-analysis to study the risk factors and clinical presentations of EIA, and differences in HBP and EGI ascariasis. Medline, Web of Science and Embase were searched for cases of EIA in the English language from India. From 1204 articles, 86 studies (105 cases) were included. The majority of the cases involved the HBP system (78%). Among HBP ascariasis, the most commonly involved site was the bile duct (53.6%). Females had 11.3 times higher odds (95% CI 2.852 to 44.856; p=0.001) of HBP ascariasis, while the pediatric population had lower odds (OR=0.323). Previous gallbladder disease was significantly associated with HBP ascariasis in adults (p=0.046), while a significantly higher number of cases of EGI ascariasis were observed among pediatric patients (p=0.003). Ocular symptoms occurred exclusively in the pediatric population (p=0.017). Overall, death was reported in 3.8% of patients (n=4). This review emphasizes the importance of the complications of EIA. It encourages future research into issues such as the reasons of higher gall bladder ascariasis in females and the implications of Ascaris-related complications following biliary tract interventions. It also suggests considering Ascaris as a differential diagnosis for airway obstuction in intubated critically ill patients.

Troubleshooting of Percutaneous Biliary Tract Intervention

Troubleshooting of Percutaneous Biliary Tract Intervention

Risk Factors for Endoscopic Biliary Tract Interventions Following Orthotopic Liver Transplantation: An Analysis of 10,252 Patients over 15 Years Across the United States

Introduction: Endoscopic biliary tract interventions following orthotopic liver transplantation (OLT) are being utilized more commonly now with advancements in endoscopic technique and technology. This study assesses the risk factors for endoscopic procedures following OLT. Method: Data on 10,252 OLT patients from the National Inpatient Sample database who underwent post-transplant endoscopic biliary procedures (EBP) was analyzed over a 15-year period (2001-2016). Results: 581 patients who had EBP were identified. Of these, 467 (80.4%) had ERCP, sphincterotomy and stenting. The remainder had ERCP alone. EBP and non-EBP patients had a similar demographic and comorbidity profile. The strongest risk factors for EBP post-OLT on multivariate analysis were biliary anastomotic stricture (OR 6.1), bile leak/fistula (OR 5.4), choledocholithiasis (OR 5.0), cholangitis (OR 4.2), age>60 (OR 2.1), living donor graft (OR 1.9), and emergency admission status (OR 1.1), p< 0.05. Conversely, roux-en-y hepaticojejunostomy and age< 20 were associated with fewer EBP, p< 0.05. EBP was associated with a significantly longer length of stay (98.3% stayed over 1 week), and higher risk of post-procedure biliary sepsis (23.2% vs 11.8%), graft abscess (11.4% vs 6%), acute graft rejection (46.1% vs 18.4%), and inpatient mortality (7.2% vs 5.3%), p< 0.05. Conclusions: OLT recipients who develop postoperative biliary complications (especially anastomotic strictures), older than 60, have living donor grafts and have non-elective admissions are at highest risk of undergoing EBP. Although unavoidable in many situations, EBP is associated with significantly greater morbidity and mortality post-OLT. Clinicians must be cognizant of these risks when considering EBP in OLT recipients. Clinical Profile of 10,252 Liver Transplant Patients from the NIS Database (2001-2016)

S1396 Intraluminal Cystic Artery Pseudoaneurysm Manifesting With Hemobilia

INTRODUCTION: Cystic artery pseudoaneurysm (CAP) is a rare cause of hemobilia and may arise as sequelae of inflammatory processes such as acute cholecystitis or surgical/procedural interventions. Its pathogenesis is posited to be due to vascular wall erosion from surrounding inflammation or, in the case of iatrogenic injury, direct vascular injury. We present a rare case of CAP arising after percutaneous cholecystostomy placement and a subsequent fall. CASE DESCRIPTION/METHODS: An 80-year-old woman with atrial fibrillation and recurrent pulmonary embolism was admitted to the hospital with acute cholecystitis. She was treated with IV antibiotics and percutaneous cholecystostomy. 5 days after cholecystostomy, the patient suffered from a fall and complained of RUQ abdominal pain and hematemesis the next day. Vitals were normal and her her abdomen was soft with RUQ tenderness. Cholecystostomy drainage bag had almost 400 mL of bloody output. Hemobilia was suspected due to the combination of bloody cholecystostomy output and hematemesis. CT abdomen demonstrated heterogeneously dense fluid (50 to 70 Hounsfield units) within the gallbladder lumen, concerning for hemorrhagic blood products, and a new cystic artery pseudoaneurysm measuring 6 mm [Figure 1]. The patient developed obstructive jaundice one day later with total bilirubin 3.8 mg/dL, direct bilirubin 3.1 mg/dL, alkaline phosphatase 635 U/L, GGT 740 U/L, AST 354 U/L, ALT 114 U/L highly suggestive of hemobilia (Quincke’s triad of obstructive jaundice, abdominal pain and GI bleeding). Repeat CT abdomen showed the cystic artery pseudoaneurysm now 1.3 centimeters [Figure 2]. Cholecystectomy with resection of the pseudoaneurysm was performed without complication. DISCUSSION: Diagnosis of cystic artery pseudoaneurysm should be considered in patients with antecedent biliary tract intervention or inflammation presenting with hemobilia. Contrast enhanced computed tomography may visualize a nodular lesion associated with the cystic artery with the same degree of enhancement as the aorta. Conventional angiography may be utilized in cases where transcatheter arterial embolism is planned and offers visualization of the pseudoaneurysm in real time. Management of cystic artery pseudoaneurysm is contingent on a patient’s clinical condition. In stable patients, cholecystectomy with surgical ligation reflects definitive management. Arterial embolization with delayed cholecystectomy may be preferred in cases of hemodynamic instability or contraindications to surgical management.Figure 1.: CT abdomen (day 9) re-demonstrating pericholecystic inflammatory changes consistent with known cholecystitis, interval development of hemorrhagic blood within gallbladder lumen, and cystic artery pseudoaneurysm measuring 6 mm (red arrow).Figure 2.: CT abdomen (day 11) axial view (A) and sagittal view (B) demonstrating interval increase in blood products within the gallbladder lumen and increased size of cystic artery pseudoaneurysm to 1.3 centimeters (red arrows).

Choledochoduodenostomy versus T-tube drainage in patients have stones in common bile duct with risk factors of post-operative missed stones

Background: Residual or missed stones of common bile duct (CBD) and ascending cholangitis after CBD exploration are major biliary surgery problems. Repeated biliary tract interventions for correction of complications are catastrophic on both patients and surgeons.Methods: This is a prospective study of 83 patients which compares two methods for surgical management of CBD stones between June 2016 to May 2018. Group I included 43 patients who were managed by CBD exploration followed by insertion of T tube, the risk factors of the incidence of missed retained stone in CBD were multiple stones in CBD and hugely dilated CBD (&gt;15 mm).The second method was choledochoduodenal anastomosis for patients having the same previous risk factors (Group II) which included 40 patients. Postoperative follow up was for 12 to 18 months.Results: In group I, 6 patients developed residual stones in CBD, reoperation was required for 3 of them and endoscopic retrograde cholangiopancreatography with sphincterotomy for another 3 patients, while in the other group (group II) 2 patients suffered from ascending cholangitis and are managed conservatively. No missed or residual CBD stones were developed and no patients need reoperation.Conclusions: With choledochoduodenostomy in patients with multiple CBD stones or markedly dilated CBD the incidence of missed or retained stones in CBD was reduced.

Percutaneous Transhepatic Biliary Interventions

AbstractBiliary tract interventions remain indispensable procedures for treatment of a wide arena of biliary tract pathologies. The increased use of endoscopic retrograde cholangiopancreatography (ERCP) for biliary tract evaluation and intervention has resulted in fewer patients requiring percutaneous transhepatic biliary interventions. However, there remains a subset of patients in whom ERCP is not feasible. Interventional radiologists play an important role in the management of biliary pathologies in such patients who cannot be benefited by endoscopic means. These interventions may at times be challenging; hence, awareness of normal and variant biliary tract anatomy and the variety of biliary tract interventions make the job easy. This article reviews the role of percutaneous transhepatic interventions in the management of a variety of biliary tract diseases, both benign and malignant, general indications and contraindications, preprocedural evaluation, and technical considerations specific to indications.

Diagnosis and Management of Complications from Percutaneous Biliary Tract Interventions-Erratum.

HomeRadioGraphicsVol. 37, No. 3 PreviousNext ErrataFree AccessDiagnosis and Management of Complications from Percutaneous Biliary Tract Interventions—ErratumNanda Venkatanarasimha, Karthik Damodharan, Apoorva Gogna, Sum Leong, Chow Wei Too, Ankur Patel, Kiang Hiong Tay, Bien Soo Tan, Richard Lo, Farah IraniNanda Venkatanarasimha, Karthik Damodharan, Apoorva Gogna, Sum Leong, Chow Wei Too, Ankur Patel, Kiang Hiong Tay, Bien Soo Tan, Richard Lo, Farah IraniNanda VenkatanarasimhaKarthik DamodharanApoorva GognaSum LeongChow Wei TooAnkur PatelKiang Hiong TayBien Soo TanRichard LoFarah IraniPublished Online:May 11 2017https://doi.org/10.1148/rg.2017174004MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Originally published in:RadioGraphics 2017;37(2):665–680 • DOI: 10.1148/rg.2017160159Diagnosis and Management of Complications from Percutaneous Biliary Tract InterventionsErratum in:RadioGraphics 2017;37(3):1004 • DOI: 10.1148/rg.2017174004Page 665, column 1, byline: The second author’s name should read as follows: “Karthikeyan Damodharan, MBBS, MRCP, FRCR.”Article HistoryPublished online: May 11 2017Published in print: May 2017 FiguresReferencesRelatedDetailsCited ByRelieving the bile ducts prior to pancreatoduodenectomy – A retrospective cohort studyWaqasFarooqui, LuitPenninga, Stefan KobbelgaardBurgdorf, Paul SunoKrohn, Jan HenrikStorkholm, Carsten PalnæsHansen2022 | Annals of Medicine and Surgery, Vol. 84Primary Clinical Application of Y-Shaped Jogged Stent Implantation in Patients with Malignant Hilar Biliary ObstructionZhongweiZhao, JingjingSong, XiaoxiFan, ShijiFang, MinjiangChen, WeiqianChen, FazongWu, LiyunZheng, JianfeiTu, JiansongJi2019 | Journal of Gastrointestinal Surgery, Vol. 23, No. 4Trans biliary proximal and distal coil embolization of an arteriobiliary fistula: report of a case and review of literatureFarisGalambo, MajidMaybody2019 | CVIR Endovascular, Vol. 2, No. 1Management of Biliary Strictures: State-of-the-Art ReviewBaljendra S. Kapoor, Giovanni Mauri, Jonathan M. Lorenz, 23 October 2018 | Radiology, Vol. 289, No. 3Accompanying This ArticleDiagnosis and Management of Complications from Percutaneous Biliary Tract InterventionsMar 13 2017RadioGraphicsRecommended Articles MR Cholangiopancreatography: What Every Radiology Resident Must KnowRadioGraphics2020Volume: 40Issue: 5pp. 1263-1264Imaging Features of Primary Sclerosing Cholangitis: From Diagnosis to Liver Transplant Follow-upRadioGraphics2019Volume: 39Issue: 7pp. 1938-1964Management of Biliary Strictures: State-of-the-Art ReviewRadiology2018Volume: 289Issue: 3pp. 590-603Diagnosis and Management of Complications from Percutaneous Biliary Tract InterventionsRadioGraphics2017Volume: 37Issue: 2pp. 665-680Secretin-enhanced MR Imaging of the PancreasRadiology2016Volume: 279Issue: 1pp. 29-43See More RSNA Education Exhibits Multimodality Imaging Review of Etiopathogenesis and Radiological Appearances of Biliary Strictures and Non-Surgical InterventionsDigital Posters2018Choosing the Best Test for Biliary Imaging: Re-Examining the Role of MRCPDigital Posters2019From Anatomy to Pathology: An Insight Into the Role of Imaging in Pediatriic Cholestasis—Let's Be a Part of the Treatment AlgorithmDigital Posters2020 RSNA Case Collection Necrotizing pancreatitisRSNA Case Collection2020Mirizzi SyndromeRSNA Case Collection2022Caroli SyndromeRSNA Case Collection2020 Vol. 37, No. 3 Metrics Altmetric Score PDF download

Diagnosis and Management of Complications from Percutaneous Biliary Tract Interventions.

Complications related to percutaneous biliary tract interventions (PBTIs) can range from access site discomfort to life-threatening vascular complications. These complications are relatively uncommon, and most of them are self-limiting. However, major complications for which an increased level of patient care and/or a prolonged hospital stay are required and that may lead to death-albeit rarely-can occur. Some of the most common complications related to PBTI include pain, infection, bile leakage, and catheter blockage. These conditions can be easily recognized by using the patient's clinical history and laboratory examination results. However, the more uncommon complications, such as life-threatening hemobilia, acute pancreatitis, and catheter and stent fractures, may have nonspecific clinical manifestations, and the underlying pathologic condition may be found only when it is being sought specifically. It is important that diagnostic and interventional radiologists be aware of the wide spectrum of PBTI-related complications, as early recognition and treatment may prevent catastrophic situations. In addition, knowledge of the different treatment options is essential for guidance in interventional radiology procedures such as transarterial control of hemobilia, imaging-guided direct percutaneous embolization of pseudoaneurysms, and percutaneous treatment of catheter- and stent-related complications such as fractures. The authors review a wide spectrum of complications associated with PBTI and the percutaneous management of these conditions. They also highlight valuable lessons learned from morbidity and mortality rounds at a high-volume tertiary care center. ©RSNA, 2017.

Bronchobiliary Fistula: A Rare Complication After Pancreaticoduodenectomy

Introduction: Bronchobiliary fistulas (BBF) are rare complications leading to communication between the thorax and biliary system. We present a case of a BBF that developed nearly a decade after pancreaticoduodenectomy (PD) for a neuroendocrine tumor.Figure 2Case: A 70-year-old man with an ampullary neuroendocrine tumor s/p PD complicated by biliary stricture and hepaticojejunostomy (HJ) anastomosis revision, presented with progressive dyspnea, fatigue and iron deficiency anemia attributed to iron malabsorption from prior bowel resections. He was transfused three units of pRBCs and discharged home. However, two days post discharge, he returned with worsened dyspnea, productive cough with bilious sputum. Initial impression was concerning for pneumonia. However, he had significant sputum output and hyperbilirubunemia. Work-up revealed cirrhosis, perihepatic ascites and right pleural effusion on right upper quadrant ultrasound. CT scan demonstrated a diaphragmatic fistula (Figure 1). Cholangiogram demonstrated a stricture at the afferent limb of HJ and biliary duct dilation (Figure 2). He was started on antibiotics and a percutaneous biliary drain was placed. He improved and was discharged. His fistula is now maintained with a biliary drain and he has had no further episodes of bilioptysis. He also receives iron sucrose infusions for chronic iron deficiency anemia.Figure 2Discussion: BBF represents a fistulous tract connecting the biliary system to the thoracic cavity, through the pleural space, lung parenchyma and bronchial tree. Risk factors for development of a BBF include conditions involving the hepatobiliary system including infection, blunt trauma or malignancy. In iatrogenic BBF, prior biliary tract intervention predates presenting symptoms by approximately 6 months. The development of BBF here likely resulted from the biliary-afferent limb anastomotic stricture after PD causing elevated biliary pressure. With the negative pressure in the thoracic cavity, the fistulous tract developed to relieve high pressure in the portal system. As bile is a strong irritant, erosions through the bronchial wall occurred leading to his presentation with bilioptysis. The patient recovered remarkably with conservative management with percutaneous biliary drain. This case highlights one mechanism for development of BBF and demonstrates that conservative management is a viable option in patients deemed to be poor surgical candidates with the potential for favorable outcomes.

Ascending Cholangitis With Normal Bilirubin in Patients With Prior Biliary Instrumentation: A Case Series

Introduction: Patients with prior instrumentation or biliary surgery may not present with classic laboratory changes associated with ascending cholangitis. Here we describe two cases of acute cholangitis in patients with normal bilirubin levels.Table 1: Laboratory Values at PresenationFigure 3Case 1: A 29 year old female was admitted with acute onset of fever, tachycardia, progressive right upper quadrant abdominal pain and nausea for several weeks. She had undergone laparoscopic cholecystectomy 9 years previously. Admission labs showed a leukocytosis, mildly elevated alkaline phosphatase (ALP) with normal transaminases and bilirubin (table 1). MRCP showed intrahepatic biliary duct dilation affecting the right system with a stricture at the site of the cholecystectomy clip. She was started on antibiotics, but her clinical status worsened over 24 hours and her labs remained unchanged. Urgent ERCP also showed the same findings and a plastic stent was placed with drainage of pus (figure 1). She subsequently improved and 10 days later underwent Roux-en-Y hepaticojejunostomy and subsequently recovered completely.Figure 1Case 2: A 77 year old female with chronic pancreatitis and recently placed covered metal stent placement for biliary stricture presented with a four days of diffuse abdominal pain, emesis, and chills. ALP, transaminases, and bilirubin were all within normal limits. She had a leukocytosis and elevated lactate (table 1). CT of the abdomen and pelvis was notable for pneumobilia and prominence of a poorly-defined pancreatic head. ERCP demonstrated that the metal stent was occluded with purulent material and was replaced with a plastic stent (figure 2). She clinically improved and one week later the temporary stents were removed. She was discharged to a skilled nursing facility for acute physical rehabilitation without recurrence.Figure 2Discussion: Ascending cholangitis with normal bilirubin has been described in primary sclerosing cholangitis (PSC) and biliary atresia (BA), but has not been reported in patients with prior biliary instrumentation or surgery. A review of the literature using the PubMed database with the search terms ‘cholangitis' and ‘normal bilirubin' found a total of 161 articles after excluding those associated with PSC and BA. No relevant reports were found. Conclusion: Physicians should have a high index of suspicion for acute cholangitis even when liver function tests are normal in patients with prior biliary tract intervention.

Complications after endoscopic sphincterotomy in liver transplant recipients: A retrospective single-centre study

Background and study aimsBiliary tract complications after liver transplantation are usually treated by endoscopic retrograde cholangiopancreatography. When biliary tract intervention is indicated, endoscopic sphincterotomy is often required. However, data regarding complication rates after endoscopic sphincterotomy in liver transplant recipients are limited. This study therefore investigated complication rates during the first 15days after endoscopic sphincterotomy in liver transplant recipients. Patients and methodsThis study retrospectively reviewed 157 consecutive liver transplant recipients who underwent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy between January 1998 and August 2013 at the University Hospital of Münster, Germany. Complications that occurred within the first 15days after the procedure were recorded, and complication rates were compared between patients who underwent conventional and precut endoscopic sphincterotomy. ResultsA total of 24 complications (15.2%) were recorded, including 9 cases (5.7%) of pancreatitis, 6 cases (3.8%) of bleeding, and 1 case (0.6%) of perforation. There were no procedure-related deaths. There were no significant differences in complication rates between the two sphincterotomy techniques. The rate of post-procedural pancreatitis decreased over time. ConclusionEndoscopic sphincterotomy is a safe procedure in liver transplant recipients. The procedure-related complication rate is reasonable and most complications can be managed conservatively.

Tomato peel: rare cause of biliary tract obstruction

Foreign bodies in the biliary tree are rare causes of obstructive jaundice. Food bezoars are infrequent as well. They can cause biliary obstruction after biliary tract interventions, or in the presence of biliary-bowel fistula or duodenum diverticulum. Food bezoars usually pass the gastrointestinal tract without any symptoms, but they can cause abdominal pain and obstructive jaundice in the case of biliary tract obstruction. Endoscopic retrograde cholangio-pancreatography has the major role in the diagnosis and the treatment of the disease. Authors summarize the medical history of a 91-year-old female patient, who developed vomiting and right subcostal pain due to the presence of tomato peel within the ductus choledochus.

Diagnosis of pyogenic liver abscess by abdominal ultrasonography in the emergency department

Background:Delayed diagnosis of pyogenic liver abscess remains a challenging problem in the emergency department because of the associated high morbidity and mortality.Objective:To evaluate the sensitivity of ultrasono-graphy in the diagnosis...

The Role of Sonography in Imaging of the Biliary Tract

Sonography is the recommended initial imaging test in the evaluation of patients presenting with right upper quadrant pain or jaundice. Dependent upon clinical circumstances, the differential diagnosis includes choledocholithiasis, biliary stricture, or tumor. Sonography is very sensitive in detection of mechanical biliary obstruction and stone disease, although less sensitive for detection of obstructing tumors, including pancreatic carcinoma and cholangiocarcinoma. In patients with sonographically documented cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy with operative clearance of the biliary stone disease is usually performed. In patients with clinically suspected biliary stone disease, without initial sonographic documentation of choledocholithiasis, endoscopic ultrasound or magnetic resonance cholangiopancreatography is the next logical imaging step. Endoscopic ultrasound documentation of choledocholithiasis in a postcholecystectomy patient should lead to retrograde cholangiography, sphincterotomy, and clearance of the ductal calculi by endoscopic catheter techniques. In patients with clinical and sonographic findings suggestive of malignant biliary obstruction, a multipass contrast-enhanced computed tomography (CT) examination to detect and stage possible pancreatic carcinoma, cholangiocarcinoma, or periductal neoplasm is usually recommended. Assessment of tumor resectability and staging can be performed by CT or a combination of CT and endoscopic ultrasound, the latter often combined with fine needle aspiration biopsy of suspected periductal tumor. In patients whose CT scan suggests hepatic hilar or central intrahepatic biliary tumor, percutaneous cholangiography and transhepatic biliary stent placement is usually followed by brushing or fluoroscopically directed fine needle aspiration biopsy for tissue diagnosis. Sonography is the imaging procedure of choice for biliary tract intervention, including cholecystostomy, guidance for percutaneous transhepatic cholangiography, and drainage of peribiliary abscesses.