Case Of Obstructive Jaundice Research Articles

Comparative study of coagulation profile in liver disease in tertiary care hospital

Introduction: The liver is the corner stone of the coagulation system and patients with liver disease are at a substantially increase risk of both thrombosis and haemorrhage. Liver acts as a reticulo endothelial system and regulates coagulation and fibrinolysis by removing these coagulation factors from the circulation. Coagulation disorders in liver disease are usually measured by the prolongation of global screening tests such as the prothrombin time and the activated partial thromboplastin time. Ingeneral, PT determines vitamin K dependent extrinsic factors VII, X, II, V and fibrinogen. The aPTT measures the activities of intrinsic and common pathways of coagulation cascade most sensitive to factor VIII, IX, XI, XII and those of the contact system. Aims and Objectives: To study the alteration in coagulation profile in various liver diseases, to evaluate the risk of bleeding in patients with liver disease and to study the association of coagulation abnormality with the extent of liver disease. Material and Methods: The study included 100 patients with liver diseases attending Medicine and Paediatric department clinics in a teaching tertiary care hospital. These patients were divided into three groups: (1) 40 cases of cirrhosis, (2) 40 cases of viral hepatitis and (3) 20 cases of obstructive jaundice. All these patients were screened for different coagulation tests like Prothrombin time (PT), Activated Partial Thromboplastin Time (APTT), Fibrinogen and Platelet count. Conclusion: Various abnormalities of coagulation tests vary greatly with different liver disorders, duration of the disorders, and their severity. There are more chances of bleeding when coagulation parameters are altered in cases of cirrhosis but more studies are required in this field to evaluate the thrombotic events seen in patients with liver diseases. Keywords: Bleeding time, Coagulation, Cirrhosis, Hepatitis, Obstructive jaundice.

S1519 A Rare Case of Obstructive Jaundice in HIV/AIDS Patient Caused by Mycobacterium

INTRODUCTION: Hepatobiliary tuberculosis (TB), lymphoma and HIV cholangiopathy are frequently reported causes of obstructive jaundice in HIV/ AIDS patients. We are presenting a rare case of obstructive jaundice due to extrinsic compression of the common hepatic duct from mycobacterial avium (MAC) adenitis of the porta hepatis associated with immune reconstitution inflammatory syndrome (IRIS). CASE DESCRIPTION/METHODS: A 55-years-old male with history of HIV/ AIDS, disseminated MAC, colon cancer and hypertension admitted with 2 weeks history of jaundice and itching. Patient denied abdominal pain, nausea, vomiting, fever, chills, weight loss, recent travel history, over the counter or herbal supplements. Medications include ethambutol, rifabutin and HAART started few months ago. Examination significant for scleral icterus otherwise unremarkable. His initial lab work-up revealed total bilirubin 30, alkaline phosphatase 1600, AST 164, ALT 78 and CD 4 count of 150. Patient underwent abdominal CT scan and MRCP which showed a 3.2 cm mass/ adenopathy at porta hepatis with malignant appearing stricture in the mid common duct with resultant moderate biliary ductal dilatation along with enlarged mediastinal, retroperitoneal and mesenteric nodes. Lymphoma, cholangiocarcinoma and metastatic disease were in the differentials. Further work up with EUS and ERCP revealed a 3.8 × 2.2 cm irregular heterogenous and poorly defined mass in the perihepatic/periportal space causing CHD stenosis. FNA was obtained. ERCP with spyglass showed a severe stricture (Bismuth I) in the CHD which appeared to be secondary to extrinsic compression. Plastic stents were placed in the RHD. Following stent placement, jaundice gradually resolved. FNA samples showed granulomatous inflammation with acid-fast mycobacterium. Decision was made to continue with current MAC and HAART treatment. DISCUSSION: IRIS is defined as a reactivation of previously treated opportunistic infections after starting antiretroviral therapy. It is more likely to occur in AIDS patients with CD4 count < 100 cells/mm. Disseminated MAC is one of the most common opportunistic infections associated with this paradoxical clinical worsening. Though some obstructive jaundice cases caused by abdominal tuberculous lymphadenitis have been reported. There have been no reports of biliary obstruction caused by the worsening of lymph node swelling due to IRIS. Endoscopic or percutaneous drainage in addition to anti-mycobacterial treatment needed.Figure 1.: EUS showing periportal/ perihepatic mass causing compression of common hepatic duct.Figure 2.: Fluoroscopy showing severe stenosis in the middle bile duct (Bismuth I).Figure 3.: Spyglass showing severe stenosis from extrinsic compression in the common hepatic duct.

S1398 Biliary Stricture in a Patient With Metastatic Mixed Germ Cell Tumor (MGCT) of the Testis: A Case Report

INTRODUCTION: Testicular cancer is the most common malignancy in American males between the ages of 15–35. Up to 95% of testicular cancers are GCTs and the most common site for metastatic spread is the retroperitoneal lymph nodes. However, the spread of the retroperitoneum rarely involves the biliary tree. We present an unusual case of MGCT of the testis with metastases to the retroperitoneal lymph nodes causing biliary stricture and common bile duct dilation. To the best of our knowledge, this is the first reported case of biliary stricture caused by metastatic testicular cancer. CASE DESCRIPTION/METHODS: An 18-year-old man with no significant past medical history presented to our emergency department with a two-week history of progressive abdominal pain and weight loss. A complete physical examination was normal except for a tender abdomen without rebound tenderness. Laboratory findings on admission revealed signs of obstructive jaundice with elevated transaminases and elevated total bilirubin. CT of the abdomen showed large retroperitoneal masses measuring 14.2 cm extending into porta hepatis region with dilatation of the biliary ducts. Further evaluation including testicular palpation and ultrasound revealed a small testicular nodule. There was an abnormal elevation of testicular markers (serum beta-human chorionic gonadotropin level was 77,193 IU/ml) which subsequently led to suspicion of testicular cancer. He underwent a biopsy of the retroperitoneal mass, which confirmed a metastatic MGCT with embryogenic and choriocarcinoma components originating from the testis. He underwent a cycle of chemotherapy with etoposide, ifosfamide, and cisplatin during his hospital stay. ERCP performed showed a severe irregular biliary stricture over the lower third of the main bile duct with malignant appearance, and the upper third of the main bile duct was severely dilated secondary to stricture. A biliary sphincterotomy was performed and biliary tree balloon sweep was conducted with no significant findings. A plastic stent was placed into the common bile duct to maintain patency and demonstrated good flow. Follow-up labs demonstrated improvement in LFTs and bilirubin levels. DISCUSSION: This is a rare case of obstructive jaundice and biliary stricture in a patient with a MGCT (non-seminomatous) of the testis that metastasized to the retroperitoneal space. After ERCP with endoscopic bile duct stenting, it was noted that the jaundice and bile duct dilation resolved and symptoms improved.Figure 1.: Coronal contrast – enhanced CT image of upper abdomen demonstrates intra- and extra hepatic biliary dilation with abrupt cut-off at the upper common bile duct (black arrow), caused by confluent retroperitoneal lymphadenopathy extending into the hepatic hilum (white arrow).

S1380 A Rare Case of Pancreatic Plasma Cell Myeloma Presenting as Obstructive Jaundice: A Case Report and Review of Literature

INTRODUCTION: Hematological malignancies affect the pancreas very rarely, with lymphomas being the most common. Pancreatic plasma cell myeloma (PCM) is exceptionally uncommon. We present a case of obstructive jaundice in a patient due to pancreatic PCM. CASE DESCRIPTION/METHODS: A 50-year old man with a history of hypertension, hyperlipidemia, and nephrolithiasis presented to the emergency department with a 3-month history of worsening mid-epigastric pain, weight loss, and jaundice. Initial laboratory workup showed low hemoglobin (11.0 g/dL), hyperbilirubinemia, and elevated protein gap. C-reactive protein and erythrocyte sedimentation rate were elevated, while vitamin B-12 and folate levels were found normal. Computed tomography revealed intra and extrahepatic biliary ductal dilatation and a hyperenhancing mass within the pancreas and porta hepatis with portal vein compression (Figure 1). Multiple enlarged retroperitoneal lymph nodes, splenomegaly, and lytic lesions in the right pubic bone were also noted. Prostate-specific antigen (PSA) and carcinoembryonic antigen (CEA) levels were normal, while CA-19-9 was found to be 191 (Normal: 0-37 U/mL). Endoscopic retrograde cholangiopancreatography (ERCP) and stenting were performed for a malignant appearing common bile duct stricture (Figure 2). Urine protein electrophoresis (UPEP) revealed a monoclonal M spike (4.7 g/dL) and gamma globulins with lambda light chains in the urine. Immunofixation confirmed the monoclonality and demonstrated IgG lambda protein. Quantitative testing showed a high level of IgG at 6.5 g/dL (Reference range: 0.7-1.6 g/dL) with decreased IgA and IgM. Biopsy of pancreatic mass and bone lesions revealed plasmacytoma with lambda light chain restriction. Bortezomib and dexamethasone were initiated with the resolution of the biliary obstruction (Figure 3). The presence of extramedullary plasmacytoma (EMP), lytic bone lesions, anemia, and monoclonal immunoglobulin production was suggestive of multiple myeloma. DISCUSSION: Pancreatic PCM typically presents with obstructive jaundice, but pancreatitis, gastrointestinal bleeding, and nausea can also occur. Pancreatic PCM offers a diagnostic challenge and should not be overlooked when evaluating hyperbilirubinemia due to obstructive jaundice if retroperitoneal lymphadenopathy and osteolytic lesions are present.Figure 1.: Arrow pointing towards pancreatic mass.Figure 2.: Arrow pointing towards common bile duct stricture.Figure 3.: Arrow pointing towards resolution of common bile duct stricture.

S1810 The Great Pretender: Painless Jaundice Caused by a Non-Hepatobiliary Source

INTRODUCTION: Painless jaundice is a known sign of obstruction from pathologies within the hepatobiliary system. Proliferation of epithelial cells may form a rare tumor known as a cholangiocarcinoma. Colorectal cancer (CRC) may metastasize to the liver parenchyma but there is no prior report of a common bile duct (CBD) tumor leading to the discovery of CRC. We present a case of obstructive jaundice which was initially thought be cholangiocarcinoma based on Computerized Tomography (CT) imaging and Endoscopic retrograde cholangiopancreatography (ERCP), but found to be hilar metastasis from an undiscovered CRC. CASE DESCRIPTION/METHODS: A 61 year-old man with no known medical history presented with complaints of jaundice, nausea, vomiting, dark urine, and right upper abdominal pain for two weeks. He denied fever, itching, weight loss, constipation or diarrhea. He was a tobacco user and had four tattoos. He denied alcohol, intravenous or other drug use. He had no recent use of acetaminophen or herbal medicine. He had no recent travel, exposure to ill contacts, history of hepatitis or risky sexual practices. His vitals were normal on presentation. On general examination the patient was an elderly man with scleral icterus but other systems, including the abdomen, were unremarkable. CT Abdomen revealed a porta hepatis mass at the CBD, concerning for cholangiocarcinoma. There were also multiple focal areas of the liver, involving the right lobe extending into segment 4 worrisome for additional large areas of metastatic cholangiocarcinoma. He was admitted for further work up. ERCP was performed, revealing a tumor extruding from the CBD. The CBD mass and a hepatic mass were biopsied. A biliary stent was placed for symptomatic relief. Immunohistochemical staining of the biopsies were negative for CK7 but positive for CK20 and CDX2, in keeping with a colonic primary. There was no clinical evidence of primary CRC but subsequent colonoscopy revealed a colonic mass with histology showing adenocarcinoma. The patient was scheduled for oncology follow up. DISCUSSION: CRC remains one of the leading causes of cancer worldwide and this case highlights an exceptionally unusual way in which this disease presented. Though a rare presentation, clinicians should be aware that it is possible for a cholangiocarcinoma to not be of primary origin. To our knowledge, this is the first known case of painless jaundice from a bile duct tumor as the initial manifestation of a primary colon cancer.Figure 1.: ERCP image showing tumor extruding from CBD.Figure 2.: Standard H&E stain of a) common bile duct tumor and b) colon carcinoma.Figure 3.: Colonoscopy image showing colon carcinoma.

S1539 A Challenging Case of Obstructive Jaundice

S1539 A Challenging Case of Obstructive Jaundice

Role of Radial Endoscopic-ultrasound (EUS) to Establish Diagnosis of Undetermined Causes of Obstructive Jaundice: A Case Series

Identification the causes of obstructive jaundice are challenging. Recent radiologic imaging techniques improve diagnostic yield to determine jaundice causes. However, small lesions particularly in pancreas or periampullary area that lead to jaundice, often unrecognize with conventional radiologic imaging. Radial endoscopic-ultrasound (EUS) is the most sensitive modality to identify the lesions-related obstructive jaundice, remarkably in the lack of high-resolution radiologic facilities. We presented four cases of obstructive jaundice, without obvious obstruction causes from conventional radiologic imaging or abdominal ultrasound. All patients underwent radial EUS, pancreatic head mass revealed in 2 patients, and distal stenosis of the common bile duct without evidence of mass was found in 2 other patients. The masses size were 16 mm and 39 mm in diameter. Due to linear EUS and EUS guided fine needle were unavailable in our center, confirmation biopsy was undone. Three patients were performed endoscopic retrograde cholangiopancreatography (ERCP) for dilatation and inserting stents, and one patient referred to the surgeon. In conclusion, radial EUS aided to diagnose the definite causes of jaundice despite in the less-equipped of high-resolution radiologic imaging.

Aetiology of Obstructive Jaundice in Ghana: A Retrospective Analysis in a Tertiary Hospital.

Background: Obstructive jaundice is a term that describes the clinical entity of yellowness of the skin and mucous membranes due to the inability of bile to flow freely into the duodenum. This is commonly due to mechanical or physiological blockage of either the intrahepatic or extrahepatic bile ducts. Malignancies are responsible for the most cases of obstructive jaundice in our locality.Aim: The study sought to analyse all cases of obstructive jaundice that presented to a tertiary referral centre over a 36-month period, to determine the age at presentation, sex distribution, and aetiological spectrum.Study Design: Retrospective cross-sectional study.Study Setting: Korle-Bu Teaching Hospital, Accra, Ghana.Materials and Methods: This was a hospital-based study of all cases of obstructive jaundice that were seen over a 36-month period from May 2017 to April 2020, at the Hepatobiliary Unit of the Korle-Bu Teaching Hospital. The unit serves as a referral centre for all liver, pancreas, and biliary tract cases, including cases presenting with obstructive jaundice. The demographic data and diagnosis of all cases of obstructive jaundice seen over the study period were retrieved from both out-patient and in-patient records.Results: Three hundred and sixty cases of obstructive jaundice were studied; 141 (39.2%) were males and 219 (60.8%) were females, giving a male-to-female ratio of 1:1.6. The mean age of the patients was 56.8 (SD, 15.9) years. Malignant conditions accounted for 314 (87.2%) cases, whilst 46 (12.8%) were due to benign conditions. The mean age of the patients with benign conditions (40.4 [SD, 15.7] years) was significantly lower than that of those with malignant conditions (59.4 [SD, 14.9] years) (P < 0.0001). There was no significant difference in sex ratios between patients with malignant and benign causes (P = 0.996). Pancreatic head cancer was the commonest malignant cause of obstructive jaundice accounting for 139 (38.61%), followed by gallbladder tumour, 81 (22.5%), whilst choledocholithiasis (23 [6.39%]) was the commonest benign cause of obstructive jaundice.Conclusion: Obstructive jaundice in our setting was more prevalent in females. Malignant aetiologies were more common than benign ones: pancreatic head and gallbladder cancers were the commonest malignancies, whilst choledocholithiasis was the commonest benign cause. Malignant causes occurred in older patients than benign conditions, but there was no difference in sex ratios between the two categories.

A case of obstructive jaundice caused by pancreatic metastasis from uterine leiomyosarcoma

A case of obstructive jaundice caused by pancreatic metastasis from uterine leiomyosarcoma

Biliary decompression in patients with obstructive jaundice

Aim. Evaluation of the biliary tract decompression methods and their use results, in patients with obstructive jaundice of various etiologies on the basis of our own clinical material.Material and Methods. A retrospective analysis of the biliary tract drain results in 6935 patients with obstructive jaundice with benign and tumor etiology. In 87% cases there was B Class of obstructive jaundice. In 93% we observed mild (A Class) obstructive jaundice. For the biliary tract drainage we used laparoscopic or open surgical access. The retrograde drain we used in sixty-seven percent cases with obstructive jaundice B Class. In sixty-six percent cases of obstructive jaundice C Class, we used antegrade drain.Results. The biliary decompression was effective in 98%. Regarding the rate and timing of bilirubin reduction, all the applied methods showed a similar result, however, the greatest number of complications and fatalities we recorded in patients after antegrade percutaneous drain of the biliary tract and transabdominal access. In 36% the performed interventions became the final treatment option, and the sixty-one percent of patients underwent two-stage treatment. The overall mortality rate was 3%.Conclusion. The use of percutaneous drainage is justified for obstructive jaundice with tumor origin, and possible radical surgical treatment. Transabdominal access drainage for benign etiology of obstructive jaundice in compensated patients can be safely used. Transduodenal endoscopic drain is an alternative to other methods biliary tract drain in severe and medium obstructive jaundice of benign etiology. The same drain method can be used for drainage of biliary tract in patients with tumors of the hepatopancreatobiliary zone organs, as a palliative treatment.

A case of obstructive jaundice in a 75‐year‐old female patient

A case of obstructive jaundice in a 75‐year‐old female patient

1362 A Rare Case of Obstructive Jaundice and Acute Pancreatitis

INTRODUCTION: Gallstones is the most common cause of both biliary pancreatitis and obstructive jaundice. Rarely, periampullary diverticula (PAD) and choledochal cysts can present with the same symptomatology. PAD is usually asymptomatic, but complications can occur in about 5% of cases. Among these, Lemmel's syndrome defined as obstructive jaundice in absence of choledocholithiasis or neoplasm and pancreatitis have been rarely reported. Choledochal cysts are abnormal dilatations of the biliary tree with type III (choledochocele) being the least common subtype, representing &lt;5% of reported cysts. Pancreatitis is the most common clinical complication and is normally the inciting event that leads to identification of the choledochocele. We present a case of recurrent pancreatitis and obstructive jaundice secondary to Lemmel's syndrome and choledochocele. CASE DESCRIPTION/METHODS: Case of a 60-year-old male with history on uncomplicated pancreatitis, who presented with nausea, vomiting, epigastric pain and fever of 2 days of duration. Physical examination with diffuse abdominal tenderness. Laboratories with leukocytosis, alkaline phosphatase 202 U/L, total bilirubin 8.3 mg/L, lipase 700 U/L and amylase 1089 U/L. Abdominopelvic CT showed acute pancreatitis, no cholelithiasis or biliary tree dilation. Magnetic resonance cholangiopancreatography showed duodenal diverticulum and choledochocele. Endoscopic retrograde cholangiopancreatography revealed a large diverticuli next to the ampulla with debris and sacular appearance of the intraduodenal portion of the common bile duct (CBD) as seen in choledochocele. The pancreatic duct was normal. A pre-cut sphincterotomy was performed. There was normalization of laboratories for which he was discharge home. DISCUSSION: Lemmel's syndrome is caused by a periampullary duodenal diverticula causing extrinsic compression of the CBD and preventing secretion of the bile. In choledochocele, there is a dilatation of the intramural portion of the distal CBD within the duodenal wall. Both diagnoses should be included in the differential of benign biliary obstruction or pancreatitis when PAD or cyst are present in imaging. In both cases, symptomatic patients can be approach with sphincterotomy. As in our case, the patient had no further episode of pancreatitis or obstructive jaundice after successful sphincterotomy. Maintaining a high index of suspicion is required to establish an accurate diagnosis since they can mimic other cystic or solid lesions around the pancreas head.

1434 A Rare Case of Multiple Myeloma Presenting as Pancreatic Plasmacytoma Causing Obstructive Jaundice

INTRODUCTION: Extramedullary plasmacytomas represent a rare type of plasma cell tumors which can present outside of the bone marrow. Although extremely uncommon, they should be considered in the differential diagnosis when it comes to obstructive jaundice and pancreatic malignancy. Here, I present a case of obstructive jaundice caused by extramedullary plasmacytoma mimicking an adenocarcinoma, diagnosed by endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). CASE DESCRIPTION/METHODS: A 72-year-old Caucasian male patient presented to our hospital with complaints of fatigue and painless jaundice. On admission, his liver biochemistries were abnormal with ALT 417, AST 414, ALP 1309, T bili 15.9, D bili 13.4, with normal lipase, amylase and WBC. CT abdomen was significant for a large mass adjacent to the pancreatic head along with multiple retroperitoneal and intra-abdominal nodules. Subsequently, patient underwent EUS with FNA of the pancreatic lesion. Tissue biopsy was positive for plasmacytoma. Follow up ERCP was unsuccessful as CBD could not be cannulated due to bulging papilla. As such, IR guided biliary drainage was placed with successful decompression of the biliary tree and corresponding improvement in liver biochemistries. Further workup showed evidence of widespread plasmacytomas including involvement of heart and bone. DISCUSSION: Pancreatic plasmacytomas remain a rare entity, with only five percent of all plasma cell tumors occurring outside of the bone marrow. This case documents a rare occurrence of visceral involvement of multiple myeloma, brought to clinical attention by atypical involvement of pancreatic head and body. Gastrointestinal plasmacytomas are usually limited to the liver and stomach, with only a limited amount of cases describing pancreatic involvement. Most reported cases describe microscopic plasma cell infiltration of the pancreas, making this presentation of a well-formed mass unusual. Availability of EUS and FNA sampling has made it easier for clinicians to diagnose plasmacytomas, as radiological differentiation of these tumors from other pancreatic malignancy is difficult. Furthermore, it is imperative to make the correct tissue diagnosis as prognosis and management differs from other pancreatic malignancy. This case highlights the importance of keeping a broad differential when suspecting a pancreatic malignancy in a patient with obstructive jaundice and those with history of plasma cell disorders.

Study of obstructive jaundice in adult: association between clinical diagnosis and operative "ndings

Obstructive jaundice is a condition in which there is blockage of the flow of bile out of the liver. To find out the correlation between clinical diagnosis and operative findings of patients having obstructive jaundice. This prospective observational study was conducted at the Department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka from January 2008 to April 2009. Fifty clinically diagnosed obstructive jaundice cases were enrolled in this study. A detailed history was taken and thorough physical examination was done. Also necessary haematological, biochemical, radiological and other special investigations were carried out. In this study, mean age of the patients was 42.9 years and male to female ratio was 1:1.17. The most frequent cause was choledocholithiasis (40%), stricture of CBD (6.0%), retained stone (14.0%), parasitic obstruction (4.0%), carcinoma (30.0%) and other cause (6.0%). Serum bilirubin level was below 10mg/dl in all cases of stricture of CBD. It was above 15mg/dL in cases of carcinoma head of the pancreas. The rise of Serum alkaline phosphates level was up to 3 folds in cases with choledocholithiasis, biliary stricture and pancreatic head malignancy. The average rise in other cases was 1 to 2 folds. Sensitivity and specificity of pre operative clinical diagnosis of choledocholithiasis, carcinoma and retain stone was 86.4 &amp; 96.4%, 92.3 &amp; 91.9% and 71.4 &amp; 95.3% respectively. Pre operative clinical diagnosis of obstructive jaundice is a good diagnosis tool in diagnosis of causes of obstructive jaundice.&#x0D; Bangladesh Med J. 2018 Jan; 47 (1): 33-36

The Radiological Study to Establish the Accuracy of MRCP over USG &amp; CT in Diagnosing the Case of Obstructive Jaundice

The Radiological Study to Establish the Accuracy of MRCP over USG &amp; CT in Diagnosing the Case of Obstructive Jaundice

Biliary Ascariasis: An Unusual Case of Obstructive Jaundice

Biliary Ascariasis: An Unusual Case of Obstructive Jaundice

Embryonal rhabdomyosarcoma of the biliary tree in a paediatric patient - A rare cause of obstructive jaundice.

Rhabdomyosarcoma (RMS) is the most common soft-tissue sarcoma in the paediatric age group, ranking fourth in frequency after central nervous system tumours, neuroblastomas and nephroblastomas. Embryonal RMS of the biliary tree is considered a rare entity, with the most common clinical presentation being that of obstructive jaundice. We present the case of a 4-year-old boy who presented with hepatomegaly and obstructive jaundice. Biochemically, there was evidence of elevated ductal enzymes with conjugated hyperbilirubinaemia. The magnetic resonance imaging (MRI) features were consistent with a biliary RMS with the differential diagnosis of a choledochal cyst initially included based on the computed tomography images. The diagnosis of embryonal biliary RMS was later confirmed on histology. This case illustrates the importance of considering malignant aetiologies in paediatric cases of obstructive jaundice, as this entity is infrequently described in the literature and may mimic the appearance of a choledochal cyst. The demonstration of enhancement of intraductal material within the biliary tree on MRI and the presence of arterial waveforms within the intraductal mass on ultrasound assists in the differentiation between biliary RMS and a choledochal cyst.

Clinical Profile and Management Techniques of Surgical Obstructive Jaundice Cases in a Tertiary Center at Bareilly

Abstract Introduction Obstructive jaundice is associated with high morbidity and mortality. Obstructive jaundice is not a definitive diagnosis. Detailed evaluation to establish the etiology of the cholestasis and cause of obstruction is crucial to avoid secondary pathologic changes and to plan different surgical techniques to intervene at an early stage. Materials and Methods A cross-sectional study was conducted among 50 cases of surgical obstructive jaundice at Shri Ram Murti Smarak Institute of Medical Sciences (SRMSIMS), Bareilly. Results The mean age of this study population was 48.44 ± 8.2 years, and 48% (24) patients had obstructive jaundice of benign etiology, whereas 52% (26) had malignant etiology. Among males, the common presentation was choledocholithiasis in benign disease and carcinoma of the gallbladder among malignancy. In females also, disease presentation was similar to that of males. Percutaneous transhepatic biliary drainage (PTBD) was the most common method of biliary decompression in malignant group. For biliary decompression in patients of benign etiology, common bile duct (CBD) exploration with T-tube drainage was done in most cases. Conclusion Obstructive jaundice has different etiologic spectrum in both males and females. Irrespective of etiology, common presentation was pain (94% of the cases). Most patients with malignant etiology presented with palpable lump. PTBD was the most common method of biliary decompression in malignant group. CBD exploration with T-tube drainage has higher values of decrease in serum bilirubin, serum bilirubin (indirect), serum alkaline phosphatase, and albumin.

A Rare Case of Obstructive Jaundice After Endoscopic Sphincterotomy

Obstructive jaundice due to formation of a biliary clot is exceedingly rare with less than 8 documented cases reported in literature to date. The pathogenic mechanism underlying these cases are biliary hemorrhaging due to endoscopic manipulation. We present a case of obstructive jaundice after endoscopic sphincterotomy due to biliary hemorrhaging and subsequent clot formation. An 87 year old female with past medical history of atrial fibrillation on Coumadin and past surgical history of cholecystectomy presented to the hospital with nausea, vomiting, fever, and RUQ pain. Labs revealed abnormal liver function and leukocytosis. CT abdomen/pelvis revealed multiple stones in the distal common bile duct, which was dilated at 1.6 cm. ERCP with sphincterotomy was performed and multiple stones were removed via balloon extraction. No post-sphincterotomy bleeding was noted at the time of the procedure. Three days later the patient developed worsening liver function, jaundice, and RUQ pain. Repeat CT abdomen/pelvis showed a small filling defect measuring 5x5 mm in the distal common bile duct. Repeat ERCP was performed and revealed an ulcerated papilla with a large, protruding blood clot. The clot was partially removed with a snare during attempted cannulation. A wire was then passed into the biliary tree through the blood clot and injection of contrast revealed a dilated common bile duct with no filling defects. A 12 mm balloon sweep of the common bile duct was performed and the blood clot was removed.1293.tif Figure 1: Blood clot seen during ERCP at the papillaPatients experiencing post-sphincterotomy hemobilia present with clinical findings indicative of hemorrhage such as fatigue, hypotension, low hemoglobin, and hematochezia. Subsequent clot formation as seen in this case can obscure the diagnosis due to signs of obstructive jaundice mimicking choledocolithiasis. Standardizing treatment for blood clots induced by endoscopic instrumentation in the setting of hemobilia has been difficult due to lack of consensus on diagnostic classification, variability in presentation, and infrequency of incidence. As suggested in literature, most cases arise within the first 10 days following biliary manipulation. Treatment modalities for clot extraction vary but typically include: nasobiliary catheter placement, balloon catheter retrieval, Dormia basket, heparin irrigation. The literature suggests improved outcomes with ERCP and endoscopic catheter retrieval, but further comparative studies of treatment modalities need to be conducted.

Extrahepatic intraductal biliary cystadenomas: Solving the mystery of “Idiopathic biliary obstruction”? A tertiary care institute experience

Introduction: Biliary cystadenoma is a rare benign neoplasm of the liver with less than 200 cases being reported all over the world. The greatest challenge in the management of biliary cystadenoma lies in the pre-operative diagnosis, since it is most often misdiagnosed as simple liver cyst or hydatid cyst. We report a series of 12 cases highlighting the radiological findings and problems related to its management with special focus on intrahepatic biliary cystadenomas; a very unusual benign cause of obstructive jaundice and their management. Case Series: Records of 12 patients who underwent surgery for biliary cystadenomas, between 2013 and 2016, were reviewed and analysed retrospectively. Of the 12 patients with biliary cystadenomas, three patients had features of obstructive jaundice in the absence of any other recognized cause of biliary obstruction. Majority of the patients were females. The most frequent symptom was abdominal pain (92%); with obstructive jaundice seen in three patients (25%). All patients were subjected to routine blood investigations with Liver function tests and in addition Serum CA 19-9 was done. We had three patients who had protruding mass like lesion into the biliary tract causing obstruction to bile flow. MRI with MRCP was done in all patients before subjecting them to surgical exploration; who were managed with extrication of the growth along with enucleation/ resection. There has been no recurrence during the follow-up period ranging from six months to three years. All 12 patients underwent surgical management which included enucleation in four patients and non-anatomical liver resection in eight patients and some in addition required T-tube drainage of the bile duct. Totally 25 cases of Biliary Cystadenomas have been managed in our Institute till date with only three cases of Obstructive jaundice. Conclusion: In patients with obstructive jaundice, especially middle aged women, with the background of normal CA 19-9 levels and a polypodal mass projecting into the bile duct lumen intraductal biliary cystadenomas should be considered as a possible diagnosis. If feasible limited resection of the cyst with extrication of this benign lesion with close follow up and frequent imaging of the liver is advisable to locate early recurrences if any.