Differential Diagnosis Of Obstructive Jaundice Research Articles

Obstructive Jaundice Secondary to Hepatic Hilar Tuberculosis Without Pulmonary Involvement.

Tuberculosis (TB) can affect the biliary system, mimicking cholangiocarcinoma without pulmonary involvement.Early recognition of biliary TB and treatment can prevent permanent complications and invasive intervention requirements.Using standard anti-tuberculous medications has shown high efficiency in treating and eradicating mycobacterial infection in such locations.

SONOGRAPHIC CRITERIA IN THE DIFFERENTIAL DIAGNOSIS OF OBSTRUCTIVE ICTERUS

The article presents the review of the literature data covering the most common causes of obstructive jaundice, methods for its differential diagnosis, as well as sonographic criteria for making a diagnosis. Based on the review, it was found that in practical surgery, ultrasound has a number of advantages in the differential diagnosis of obstructive jaundice. Sonography is an affordable, non-invasive method with high information content, allowing to make a diagnosis in the shortest possible time. The main reliable sonographic criteria for the obstructive genesis of icterus is prestenotic dilatation of the bile ducts. However, since the interpretation of ultrasound results is subjective and depends on the qualifications of the ultrasound specialist, verification of sonographic information by other research methods is necessary.

Biliary Tract Rhabdomyosarcoma: A Challenging Diagnosis

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children. It is located mainly in the head and neck, extremities and trunk, rarely achieving the biliary tract (1%). The clinical presentation is characterized by obstructive jaundice, abdominal pain and palpable mass. The prognosis is favourable when being early diagnosed. The main differential diagnosis is the choledochal cyst. We bring a case report about a patient with biliary tract rhabdomyosarcoma, diagnosed and treated for 1 year as choledochal cyst, presenting obstructive jaundice for one year. A hepatic biopsy was done, showing hepatic fibrosis. He presented clinical worsening and was referred for liver transplant. An exploratory laparotomy was done before planning the transplant, which showed a biliary tract mass, followed by a biopsy. The anatomopathological result was RMS. Biliary tract RMS is a rare entity that should be included in the differential diagnosis of obstructive jaundice in children. Because of its similarity with choledochal cyst, pediatricians and surgeons should consider this hypothesis, for adequate investigation and treatment.

IGG4-related Sclerosing Cholangitis Mimicking Cholangiocarcinoma: A Case Report

Introduction: IgG4-related sclerosing cholangitis may have variable clinical presentations and may sometimes mimic cholangiocarcinoma. We present a case of a 42-year-old male with IgG4-related sclerosing cholangitis who was initially diagnosed as cholangiocarcinoma. Case report: A 42-year-old gentleman presented with history of progressive jaundice for one month associated with generalized weakness and loss of appetite. His total and direct bilirubin were 5.7 and 4.8 mg/dl, respectively, with an ALP of 1570 U/L. CECT revealed an ill-defined soft tissue enhancing component infiltrating the lumen of the common hepatic duct, distal cystic duct, and proximal common bile duct. In addition, the MRCP of the patient showed an ill-defined lesion around the gall-bladder neck that was effacing a part of the distal cystic duct and a long segment of common hepatic duct suspicious of cholangiocarcinoma. With a provisional diagnosis of cholangiocarcinoma, the patient was subjected to diagnostic laparoscopy, which revealed scirrhous tissue encasing the proper hepatic artery and portal vein and prominent lymph nodes around the hepatoduodenal ligament. There were no ascites or evidence of peritoneal metastasis. Biopsy of the lesion revealed inflammatory cells comprising of lymphocytes, plasma cells, and eosinophils; there were no atypical or malignant cells. IgG-4 marker was positive and immuno-reactive in 5-6% of plasma cells. The patient’s symptoms were completely relieved after three months of steroid therapy. Conclusion: IgG4 -related sclerosing cholangitis can mimic cholangiocarcinoma. Although the disease is rare and its diagnosis remains challenging, knowledge of the disease is valuable when considering the differential diagnosis of obstructive jaundice.

Non-hodgkin lymphoma presenting with obstructive jaundice - diagnostic dilemma

Introduction: Obstructive jaundice is seldom a presenting feature of non-Hodgkin lymphoma (NHL). Indeed, several case reports suggest that only 0.2-2.0% of patients with NHL have biliary tract obstruction. Adenocarcinoma arising from the pancreas, bile duct, duodenum are among the common cause of obstructive jaundice worldwide. Hence NHL is rarely considered among differential diagnosis of obstructive jaundice. Methods: We present a case series of 4 patients with NHL presenting with obstructive jaundice as an initial manifestation. The aim was to evaluate the clinical and imaging findings, management, and outcome of biliary obstruction caused by lymphoma. Results: All 4 patients presented with obstructive jaundice with duration ranging from 2 weeks to 4 months. 3 patient had pancreatic mass with lower CBD block and one had hilar block on CECT abdomen. All cases were diagnosed by endoscopic and biopsy. 2 patients presented with cholangitis and stented to relieve sepsis. One patient had poor ECOG status so only stenting was offered but succumbed within a month of diagnosis. 2 patient died of sepsis and multiorgan failure before initiating chemotherapy and only one patient had undergone chemotherapy. Conclusion: Biliary obstruction is a sign of poor prognosis. The diagnosis of NHL needs to be considered in patients presenting with biliary obstruction. It can be associated with high mortality and poses treatment dilemma. Treatment of biliary obstruction due to lymphoma is controversial regarding chemotherapy alone versus biliary drainage preceded by chemotherapy. Biliary drainage is recommended in patients with infectious complication.

Rhabdomyosarcoma of the common bile duct mimicking choledochal cyst: a rare cause of obstructive jaundice

Extrahepatic biliary tract tumors are rare and among them rhabdomyosarcoma is most common. Rhabdomyosarcoma is a soft tissue malignant musculoskeletal tumor and is a very rare malignancy of the common bile duct in children. It usually presents as obstructive jaundice and/or pruritus. If there is no local invasion to the adjacent tissues, the radiological appearance of the tumor lesion is like a choledochal cyst. So the diagnosis is usually made at surgery or by preoperative biopsy. It is important to diagnose early and differentiate it from choledochal cyst and start treatment as early as possible for long time survival of the patient. This case report presented a case of a 10-year-old boy with recurrent onset of obstructive jaundice and fever preoperatively who was diagnosed as choledochal cyst and postoperatively as embryonal rhabdomyosarcoma of the common bile duct. After surgical resection and postoperative chemotherapy, the child had a good prognosis. So it is crucial to know that this rare tumor can mimic congenital choledochal cyst and it should be considered in the differential diagnosis of obstructive jaundice in children.

Case Report: Painless obstructive jaundice caused by IgG4 autoimmune pancreatitis; the role of endoscopic ultrasound in diagnosis

We report the case of a 60-year-old woman, presenting with painless obstructive jaundice of unknown etiology, who was finally found to suffer from type I autoimmune pancreatitis (AIP). This case emphasizes AIP as a rare cause in the differential diagnosis of obstructive jaundice and the role of endoscopic ultrasound (EUS) in final diagnosis, which is difficult to establish. According to diagnostic criteria, we combined the results from serologic, imaging and histological features (specifically lgG4 levels, computed tomography, magnetic resonance imaging/magnetic resonance cholangiopancreatography and EUS) with cytological results, leading to a final diagnosis. Our patient’s response to corticosteroids was impressive, confirming the diagnosis, leading to complete remission of the disease. Whilst diagnosis of AIP is challenging, the application of diagnostic criteria can lead to correct diagnosis. Therapy is corticosteroid based, with very satisfying outcomes.

Value of radiology techniques for diagnosis of obstructive jaundice in admission department

Obstructive jaundice may be caused by many different diseases associated with bile duct obstruction leading to severely impaired liver function as well as injuries of other organs and systems. Early identification of the causes and nature of hyperbilirubinemia is of paramount importance in patient management and decreases the incidence of serious complications and fatalities. Radiology techniques are extremely helpful for the differential diagnosis of obstructive jaundice. High awareness of these methods’ possibilities and their rational use allow one to choose the most appropriate treatment strategy and determine disease outcome. The article describes the feasibility and proper order of various diagnostic methods’ application for examining patients with suspected obstructive jaundice.

An Unexpected Cause of Obstructive Jaundice: A Case of Lemmelʼs Syndrome

An 83 years old female was evaluated at the ED presenting with abdominal pain for two weeks, anorexia, nausea, fatigue, dark urine and yellowing of the skin. Her past medical history included hypertension, dyslipidemia, major depressive disorder and prior cholecystectomy. Her medication profile included losartan 50mg/HCTZ 12.5mg and Sertraline 50mg. She had a family history of pancreatic and breast adenocarcinoma in a sibling. Physical examination was remarkable for jaundice, scleral icterus, transverse right upper quadrant abdominal surgical scar, with mild epigastric tenderness upon palpation. Laboratory work-up revealed WBC 6.28, AST 725IU/L, ALT 1059IU/L, alkaline phosphatase 130IU/L, amylase 53IU/L, lipase 23IU/L and bilirubin 30mg/dL. Contrast enhanced abdominal CT revealed an outpouching along the second portion of the duodenum, compatible with a periampullary duodenal diverticulum, resulting in biliary dilatation with extensive perihepatic edema. Endoscopic retrograde cholangiopancreatography(fig.1) confirmed a large, diverticulum, 0.5cm from the ampulla of Vater with debris(fig.2), without evidence of choledocholithiasis or pancreatic abnormalities. Endoscopic sphincterectomy was performed and clinical recovery was observed. Diverticula of the gastrointestinal tract are outpouchings of all or part of the intestinal wall. The duodenum is the second most common site of diverticula in the gastrointestinal tract. Among duodenal diverticula, periampullary diverticula (PAD) are the most common type comprising about 70% to 75% of all duodenal diverticula. PAD develops within the radius of 2 to 3 cm from the ampulla of Vater. Most PAD are asymptomatic but complications can occur in about 5% of cases. Rarely, duodenal diverticula may present with obstructive jaundice, in the absence of cholelithiasis or other detectable cause, known as Lemmel's syndrome. Imaging studies such as contrast enhanced abdominal CT and MRCP may be suggestive of Lemmel's syndrome; however, direct visualization by ERCP remains the gold standard for diagnosis. Diverticulectomy is standard of care for treatment, nonetheless there are additional options such as papillary balloon dilatation, conservative medical management or endoscopic sphincterectomy, as in our case. Knowledge of such condition is important, since misdiagnosis could lead to delay in treatment. Lemmel's syndrome should always be included in the differential diagnosis of obstructive jaundice in a patient with PAD.Figure: ERCP showing biliary dilatation.Figure: ERCP showing periampullary diverticula with debris.

Acute biliary obstruction with cholestasis caused by Fasciola hepatica in a patient travelled to Turcmenistan (a case report and literature review)

The paper describes the case of Fasciola hepatica in patient from Turkmenistan presenting with icterus, biliary-type pain, dark urine and jaundice. Magnetic resonance (MRC) and endoscopic retrograde cholangiography (ERC) were performed and after sphincterotomy one Fasciola hepatica was extracted. After the ERC antiparasitic treatment was given with triclabendazole. Clinical outcome was favourable. In conclusion, fascioliasis should be considered in the differential diagnosis of obstructive jaundice, especially in patients travelled to endemic regions, and it should be kept in mind that ERC and triclabendazole play an important role in the diagnosis and treatment of these patients. To our knowledge, this is the first case report of Fasciola hepatica treated by ERC in Russia.

Isolated hepatobiliary cryptococcosis manifesting as obstructive jaundice in an immunocompetent child: case report and review of the literature

The majority of patients with symptomatic cryptococcosis have an underlying immunocompromising condition. In the absence of coexisting immunocompromising condition, Cryptococcus neoformans is rarely considered in the differential diagnosis of obstructive jaundice that occurs in children with hilar masslike lesion. Here, we report a 5-year-old boy without immunoglobulin or lymphocyte abnormalities who developed a hepatobiliary infection with C. neoformans. Ultrasonography and computed tomography showed dilatation of the bilateral intrahepatic bile ducts and a low-attenuated mass in the hepatic hilum. Microscopic examination of tissue samples revealed abundant numbers of encapsulated yeast cell suggestive of C. neoformans. After 4 months of antifungal therapy (liposomal amphotericin B for 2 weeks and oral fluconazole for 3 months), the disease was effectively controlled. Unnecessary operation could be avoided by an early and accurate diagnosis. By sharing our experience, we suggest hepatobiliary surgeons and gastroenterologists should have a suspicion of this unusual entity to make earlier diagnosis and treatment.

Obstructive jaundice due to a rare periampullary tumor

Gangliocytic paraganglioma is a rare neuroendocrine tumor predominantly arising in the second part of the duodenum with rare local recurrence or metastasis to regional lymph nodes. A 92-year-old female presented with obstructive jaundice. On exam she had pale conjunctiva and icteric sclera. Abdominal examination revealed tenderness in the upper abdomen. Laboratory data was consistent with obstructive jaundice. Computed tomography of the abdomen revealed a dilated gall bladder and a common bile duct (CBD) with no evidence of liver lesions or pancreatic head mass. Endoscopic ultrasonography revealed a 1 cm isoechoic submucosal nodule at the periampullary area, dilated CBD (9 mm), a prominent pancreatic duct (4.1 mm) and a hydropic gall bladder with no stones. Endoscopic retrograde cholangiopancreaticography was performed to relieve obstruction and showed a 1 cm periampullary mass which underwent an en-bloc snare resection. Histopathology analyses with immunohistochemical stains were positive for cytokeratin, synaptophysin, S-100 protein, neuron specific enolase and negative for actin and desmin consistent with periampullary gangliocytic paraganglioma. Periampullary gangliocytic paraganglioma is a rare benign tumor of the small bowel. Common presentation includes abdominal pain and obstructive jaundice which should be included in differential diagnosis of obstructive jaundice. Endoscopic resection is a curative therapy in the absence of local invasion or distant metastasis.

English

  Obstructive jaundice secondary to Burkitt’s lymphoma (BL) is very rare. It is important to recognise   this   condition   as   it   can  mimic  adenocarcinoma  of  the  pancreas,  but the management of the two conditions is very  different.  In  this  study,  we  present  the case of a seventy-nine  year  old  male  with  right  upper  quadrant  pain,  jaundice,  and pruritus. It is crucial to consider BL as a differential diagnosis of obstructive  jaundice as both the prognosis and treatment are markedly different. Key words: Burkitt’s, Jaundice, lymphoma, adult.

Pancreatic Involvement by Plasma Cell Neoplasms

Pancreatic involvement by plasma cell neoplasms is an extremely rare event, with only 50 cases described in the literature. They can present as a primary solitary extramedullary plasmacytoma or plasmacytoma secondary to a plasma cell myeloma. Clinical manifestations are due to the presence of a pancreatic mass usually in the pancreas head, which causes extra-biliary obstruction and abdominal pain. Abdominal imaging including CT scan or endoscopic ultrasound with fine-needle aspiration tissue sampling is essential for the initial diagnostic procedure. However, immunohistochemical analysis of the biopsy specimen or flow cytometry of the aspirated material is crucial to prove the monoclonality and the final diagnosis of a plasma cell neoplasm. Management of these situations include radiotherapy, chemotherapy, surgery or combined therapy. Novel medications including the immunomodulatory drugs or the proteasome inhibitors followed by consolidation with intensive chemotherapy and haematopoietic stem cell transplantation are nowadays used as upfront treatment in the cases associated to a plasma cell myeloma. Despite the rarity, plasma cell neoplasms should be considered in the differential diagnosis of obstructive jaundice and pancreatic neoplasms since they are potentially treatable situations.

A ductus choledochus adenomyosisa

A woman 80 years of age had diffuse adenomyosis in the wall of the choledochus, near to the papilla of Vater. The lesion caused icterus and was operated (partial pancreatoduodenectomy). Adenomyosis should be considered in the differential diagnosis of obstructive jaundice.

Biliary Non-Hodgkin Lymphoma Detected by F-18 FDG PET/CT

Abstract: Biliary involvement by non-Hodgkin lymphoma is rare with an incidence ranging from 0.5% to 2%. In this article, we describe fluoro-deoxy-glucose (FDG) avid common bile duct involvement in a patient being staged for diffuse large B-cell lymphoma with F-18 FDG positron emission tomography/computed tomography (PET/CT). We conclude that FDG PET can be a convenient noninvasive method of imaging extrahepatic biliary obstruction due to a lymphoma which should be considered in the differential diagnosis of obstructive jaundice in such patients. A positive FDG PET warrants histopathological correlation for appropriate treatment.

Primary extranodal non-Hodgkin’s lymphoma of the common bile duct manifesting as obstructive jaundice: Report of a case

Primary non-Hodgkin's lymphoma (NHL) of the common bile duct (CBD) manifesting as obstructive jaundice is extremely rare: to our knowledge, only 22 cases of primary NHL arising from the CBD have been reported. The patient in this case report was a 63-year-old man who presented with obstructive jaundice. Abdominal sonography, positron emission tomography, and computed tomography showed a mass with abnormal 18-fluorodeoxyglucose uptake in pancreatic head. Magnetic resonance cholangiopancreatography demonstrated a strictured segment of the CBD with proximal bile duct dilatation. We performed pancreaticoduodenectomy for a presumptive diagnosis of pancreatic head carcinoma or cholangiocarcinoma of the CBD. However, the histological diagnosis was a primary, diffuse, large B-cell lymphoma of the CBD. He received three courses of combination chemotherapy, including rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). The patient remains well, without evidence of tumor recurrence, 8 months after surgery. In summary, primary NHL of the CBD, despite its rarity, should be considered in the differential diagnosis of obstructive jaundice. An accurate histopathologic diagnosis and complete surgical resection, followed by combination chemotherapy plus rituximab may be effective.

Extramedullary plasmacytoma of the pancreas as an uncommon cause of obstructive jaundice: a case report

IntroductionThough uncommon, extramedullary plasmacytoma of the pancreas should be considered in the differential diagnosis of obstructive jaundice and pancreatic neoplasms. This report highlights a case of obstructive jaundice in a 46-year-old West Indian man that resulted from an extramedullary plasmacytoma.Case presentationA 46-year-old West Indian man presented to our hospital with evidence of a significant upper gastrointestinal bleed. He gave a recent history of jaundice, constitutional symptoms and back pain. Ultrasonography revealed a mass in the head of the pancreas with resultant common bile duct dilatation. The patient required urgent surgical intervention for ongoing bleeding at which time a biopsy of the pancreas was taken. Histological analysis revealed a plasmacytoma of the pancreas. A blood film showing rouleaux formation and a skeletal survey demonstrating multiple lytic lesions confirmed multiple myeloma. Before further evaluation or treatment was carried out, the patient defaulted from follow-up and died from his illness seven months later.ConclusionThis case represents an example of multiple myeloma with visceral involvement, brought to clinical attention through involvement of the pancreas. The report serves to reaffirm knowledge of the various presentations, the optimal diagnostic tools and the current proposed treatment strategies for extramedullary plasmacytomas of the pancreas.

Zweifache Ursache eines Verschlußikterus: Cholangiolithiasis und maligne Choledochusstenose*

Endoscopic retrograde cholangiopancreatography in a 78-year-old woman with right-sided upper abdominal pain and jaundice (total bilirubin 8.9 mg/dl) revealed two stones, of about 1 cm diameter each, in the biliary duct. They were removed after papillotomy. Because of persisting jaundice (total bilirubin 7.6 mg/dl) and a history of two years of recurrent cholecystitis a cholecystectomy was performed. At operation an advanced carcinoma of the gallbladder was discovered, with tumour compression of the extrahepatic choledochal duct. After removal of the gallbladder the stenosis was bridged with a T-drain. For permanent bile diversion of a self-expanding stent was endoscopically implanted. The patient has been symptom-free so far for 6 months. It is stressed that, especially in elderly patients, malignant choledochal stenosis must be included in the differential diagnosis of obstructive jaundice caused by stones and diagnostic procedures undertaken accordingly.

Biliary Tract Obstruction Secondary to Malignant Lymphoma: Experience at a Referral Center

Lymphoma is a rare cause of biliary obstruction and, on cholangiography, may mimic other causes of obstructive jaundice. The optimum treatment for these patients is unclear. The aim of this study is to evaluate the incidence, clinical and imaging findings, management, and outcome of biliary obstruction caused by lymphoma. Our database was searched retrospectively for patients with biliary obstruction due to lymphoma between 1999 and 2005. Biliary obstruction secondary to lymphoma was found in 7 (0.6%) of 1123 patients with malignant biliary obstruction. One patient had benign biliary obstruction related to lymphoma. Of the eight patients (five male, three female; mean age, 34.50 +/- 17.93 years), four had Hodgkin's disease and four had non-Hodgkin's lymphoma. Biliary obstruction occurred as part of the initial or early presentation of lymphoma in two patients. The most common cause of obstruction was compression of the biliary tract by enlarged lymph nodes (six patients). Cholangiographic appearances were diverse: narrowing of the common bile duct (six patients), splayed and narrowed common bile duct (one patient), and multiple strictures and dilatations of the intrahepatic bile ducts (one patient). Biliary drainage was performed in all patients including endoscopic stent placement in six patients, nasobiliary drainage in one, and choledochoduodenostomy in one. Hyperbilirubinemia resolved in all but one of the patients with a stent; however, none could be maintained in a stent-free condition. Five patients died within 1 year after onset of jaundice. One of the surviving patients developed a late benign stricture at the site of the earlier lymphoma. We conclude that lymphoma should be considered in the differential diagnosis of obstructive jaundice, particularly in younger patients. We suggest that biliary drainage by the endoscopic or percutaneous route is necessary for the treatment of these patients. Late benign strictures may develop. Biliary obstruction is a sign of poor prognosis in lymphoma.