Dilated CBD Research Articles

Role of Intraoperative Cholangiography in Laparoscopic Cholecystectomy in Higher Risk Patients of Bile Duct Injuries

AbstractBackground: Intraoperative Cholangiography (IOC) during Laparoscopic Cholecystectomy (LC) is a radiologic contrast-based examination of the bile duct which can represent a systemic approach to avoid Bile Duct Injuries (BDIs).Aim of Study: The aim of this study was to evaluate the protective effect of selective use of IOC during laparoscopic cholecystectomy in patients with high risk for Bile Duct Injuries (BDIs).Patients and Methods: This was a prospective study included 23 patients who presented for laparoscopic chole-cystectomy and had risk factors for bile duct injuries, under-went LC with IOC. Cases were analyzed as regard operative details and clinical outcomes.Results: Cholangiography was successful in all the cases. The mean time of IOC added to LC was 22 minutes. There was a longer LC and IOC time in cases with positive CRP, pericholecystic fluid, mucocele and pyocele with positive significant differences. Although the pre-operative data 47.8% had history of obstructive jaundice, 21.7% a mucocele cases, 17.4% a pyocele cases, pericholecystic fluid in 30.4% and dilated CBD in 65.2%, only 13% showed abnormal IOC and needed further therapies (intraoperative ERCP in 2 cases and CBD exploration in 1 case). No bile duct injury in any case.Conclusion: Intraoperative Cholangiography (IOC) was found to be safe, taking only an additional time of 22 minutes to total operative time. Although the pre-operative data, only 13% of cases needed further therapies (ERCP or CBD explo-ration). The use of IOC could be considered to improve patient safety and long term results.

Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system.

The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale. Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets. Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773-0.806, p < 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries. We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research.

Recurrence of common bile duct stones following laparoscopic common bile duct exploration: a multicenter study.

Recurrence of common bile duct stone (CBDS) is not common after laparoscopic common bile duct exploration (LCBDE). This study aimed to investigate the risk factors of recurrence of CBDS after LCBDE. Patients who underwent LCBDE between January 2001 and December 2018 in four teaching hospitals of The Catholic University of Korea were included. The operation, fluoroscopy, and endoscopic retrograde cholangiopancreatography records were investigated retrospectively. The primary outcome of this study was the independent risk factors for recurrence of CBDS. A total of 230 patients were included in this study. Thirty-one patients had recurrence of CBDS. In univariate analysis, CBDS size (>9mm) (P=0.003), multiple stones (≥2) (P=0.031), stone size (≥1.5cm) (P=0.041), CBD diameter (≥12mm) (P=0.005), CBD dilatation (≥10mm) (P=0.02), prior history of laparoscopic cholecystectomy (P=0.002) were associated with recurrence. After multivariable logistic regression, CBDS size (>9mm) (OR 4.67, 95% CI 1.35-16.18, P=0.011), CBD dilatation (≥10mm) (OR 5.66, 95% CI 1.47-21.82, P=0.012), and prior history of laparoscopic cholecystectomy (AOR 3. 90, 95% CI 1.34-11.37, P=0.013) were associated with recurrence. Stone size>9mm, CBD diameter≥10mm, and prior history of laparoscopic cholecystectomy were risk factors for recurrence of CBDS after LCBDE.

2999 Is There Truth to the Numbers?

INTRODUCTION: CA 19-9 is a tumor marker associated with pancreatic and biliary tumors that can be directly measured in the blood with a normal range of 0-37 units/mL. Other inflammatory conditions such as biliary obstruction can also cause an elevation, which can obfuscate the diagnostic and prognostic value of CA 19-9. CASE DESCRIPTION/METHODS: A 66-year-old male with no medical history presented with a 1-month history of abdominal pain, jaundice, and weight loss. He was febrile at 100.4 F. Bilateral conjunctival icterus, full upper body jaundice, hepatomegaly, and mild tenderness to deep palpation in the right upper quadrant and epigastric regions were noted on exam. Gallbladder ultrasound revealed significant common bile and intrahepatic duct dilation concerning for obstructive lesion with no gallstones and minimal sludge. Total bilirubin was 27 mg/dL. CA 19-9 was elevated at 9,272 units/mL. CT abdomen and pelvis with contrast confirmed severe common bile and intrahepatic duct dilation with CBD measuring up to 22 mm. MRCP revealed marked intrahepatic and extrahepatic biliary dilation with dilated CBD up to 24 mm and choledocholithiasis with the largest gallstone measuring 15 mm in the distal CBD. ERCP revealed CBD stricture and sphincterotomy was performed with temporary stent placement. Ceftriaxone and metronidazole were given for ascending cholangitis. Fine needle aspiration was done by EUS, which was negative for malignancy on pathology. Repeat MRCP showed improvement in dilation and CBD now at 14 mm. Repeat CA 19-9 was 193 units/mL. Of note, CT chest with contrast did not reveal any evidence of pulmonary metastasis, CEA level was normal, and hepatitis panel was negative. DISCUSSION: A CA 19-9 cutoff of greater or equal to 300 unit/mL have been reported to have a specificity of 87% for cancer in patients with cholangitis. However, an extremely elevated CA 19-9 level does not always equal cancer or correlate with tumor burden and should not be used as the sole criterion for a diagnosis of malignancy. Non-cancerous causes of elevated CA 19-9 include gallstones, cholangitis, bile duct obstruction, and pancreatitis. EUS was critical in obtaining tissue to exclude pancreatic and biliary cancer. CA 19-9 and total bilirubin levels dropped after CBD stent placement, supporting a diagnosis of cholangitis without tumor. This is a rare case of extreme tumor marker elevation caused by choledocholithiasis and cholangitis, which serve as a cautionary tale of not relying too heavily on numbers to treat the patient.

3032 Acute Presentation of Undiagnosed Pancreatic Cancer With Fatal Prognosis

INTRODUCTION: Most common presentation of pancreatic cancer are abdominal pain, weight loss and jaundice. However, these symptoms manifest mostly with advance disease and are non-specific making the early diagnosis difficult. Consequences of missing diagnosis can be fatal leading to metastatic disease and decease life expectancy. We came across similar case with obstructive jaundice and had pancreatic mass with life span of 2 months after diagnosis. CASE DESCRIPTION/METHODS: 69 years old male was admitted for a mechanical fall. His past medical history included CAD, chronic pancreatitis, and diabetes mellitus. He reported 6 days history of pale stools and dark urine which resolved 2 days prior to presentation but had some associated chronic abdominal pain with 50 lb unexplained weight loss over past 6 months. On examination, he was found to have scleral icterus and jaundiced skin. On blood work, he was noted to have AST 242, ALT 477, ALP 508, and bilirubin 13.0 and direct bilirubin of 10.4. All values were normal one month prior to current admission. Abdominal ultrasound showed dilated CBD to 15 mm, intrahepatic ducts and a distended gallbladder without stones. He underwent MRCP and was found to have dilated CBD with 13 mm diameter, intrahepatic biliary ducts, and distended gall bladder with abrupt cut off of the distal CBD. There is also dilatation of pancreatic duct measuring up to 11 mm with a cut off of the proximal pancreatic duct by a large amorphous mass. ERCP was done, but wire passage in CBD was restricted by possible tumor which lead to limitations like lack of biopsy and stent placement. PET CT showed fullness in pancreatic head with increased FDG uptake. He underwent cholecysto-gastrostomy for internal biliary decompression and was noted to have distended gallbladder, and fibrotic pancreas with no pancreatic mass. Bilirubin dropped the surgery. Patient refused invasive procedures afterwards for tissue diagnosis of cancer. He died 2 months after surgery. DISCUSSION: Pancreatic cancer is fourth leading cause of cancer related deaths in United States. Incidence increases after the age of 45 with more male to female ratio 1.3:1. USPSTF found no evidence of improved mortality with screening in asymptomatic patients. Surgical resection is only curative with less role among patients with late presentation emphasizing the importance of early diagnosis. Physician should have high suspicion among patients with risk factors to avoid deadly complications.

3021 Recurrent Obstructive Jaundice from Iatrogenic Pancreatic Duct Stricture

INTRODUCTION: There is always an intrinsic risk of complications with ERCP. The most common early complication include pancreatitis, followed by infection, bleeding and perforation.1 Late complications include pancreatic ductal and parenchymal changes, stent migration and malfunction due to occlusion. Here we present a case of an elderly man with recurrent obstructive jaundice and underwent multiple ERCP. CASE DESCRIPTION/METHODS: An 81 years old man was admitted for two weeks history of dark brown urine, light brown colored stools and diffuse itching of the skin. His past medical history included HTN and HLD. He had admission for similar symptoms twice within last one year. On initial admission, he was noted to have obstructive jaundice picture with multiple gall stones, dilated intrahepatic ducts, CBD and pancreatic duct. He underwent ERCP with removal of multiple small gall stones and later underwent cholecystectomy with normal liver functions on follow up. He required sphincteroplasty on later admission. He denied fever, chills, abdominal pain, weight loss, nausea, vomiting, and changes bowel habits. He denied alcohol or any drug abuse. On physical examination, he was afebrile, and was found to have scleral icterus, yellowish discoloration of skin and excoriations in extremities. Laboratory investigation revealed worsening hepatic function with ALT 192, AST 140, ALP 779, GGT of 1098, total bilirubin of 11.3 and direct bilirubin of 8.1. Other blood test results were normal including WBCs, serum electrolytes, TSH, toxicology screen, kidney functions, viral hepatitis panel and coagulation profile. US abdomen showed dilated common bile duct to 18 mm, pancreatic duct and intrahepatic ducts. MRCP showed persistent chronic CBD dilated to 14 mm, pancreatic duct to 4 mm and marked intrahepatic biliary dilatation and a focal stricture was seen in proximal pancreatic duct. He underwent ERCP and was found to have ampullary stenosis. Sphincterotomy was performed. His signs and symptoms resolved on follow up visit. DISCUSSION: It is challenging to diagnose biliary strictures. Most pancreatic duct stricture are iatrogenic from operative trauma. Moreover, it is difficult to estimate the procedural complications as there is always an inherent bias and patient underreporting. However, ERCP is associated with fourfold increased rates of severe complications than other endoscopic procedures. To avoid these complications, the procedure should be performed by experienced provider and trend towards therapeutic approach as opposed to diagnostic approach.

2337 Secondary Sclerosing Cholangitis and Nodular Regenerative Hyperplasia Caused by Hereditary Spherocytosis

INTRODUCTION: Hereditary spherocytosis is a hemolytic anemia that leads to premature cell destruction due to red cell membrane defect. It causes release of unconjugated bilirubin, and subsequent bilirubin gallstone formation occurs. Chronic recurrent choledocholithiasis can cause secondary sclerosing cholangitis (SSC). Hemolysis can lead to chronic vascular injury and portal vein thrombosis, resulting in Nodular Regenerative Hyperplasia (NRH). Here, we report a case of HS causing SSC with concurrent NRH. CASE DESCRIPTION/METHODS: A 37-year-old female with a history of hereditary spherocytosis with thrombocytosis presented to the office for abnormal liver function tests (LFTs). History of splenectomy and cholecystectomy in 2002. Patient was noted to have abnormal LFTs in 2009 (Figure 1). Her LFTs were routinely monitored until 2016 when she presented with epigastric pain, jaundice, and abnormal LFTs. Viral and autoimmune hepatitis serologies were negative. Iron studies were normal. Right upper quadrant (RUQ) ultrasound (US) showed mildly dilated intrahepatic ducts. Magnetic resonance cholangiopancreatography(MRCP) was performed which showed a questionable stricture in the proximal CBD and mild dilatation of the central intrahepatic duct. ERCP showed normal caliber CBD with multiple filling defects. A biliary sphincterotomy was performed and the stone was removed. ERCP performed in 2016 and 2018 revealed multiple stones in the biliary ductal system, which were removed and the CBD was dilated. Liver biopsy showed mild portal and lobular inflammation with mild portal fibrosis and changes suggestive of NRH. DISCUSSION: HS caused the patient's recurrent choledocholithiasis and contributed to SSC. Pathologically, SSC causes inflammation, obliterative fibrosis, stricture formation, and destruction of the biliary tree, which leads to biliary cirrhosis. Although often reversible, outcomes may not be as favorable if it is not recognized quickly, particularly in critical illness induced SSC. NRH is a liver disease characterized by many hyperplastic nodules without separation by fibrotic tissue. It is associated with any systemic disease that causes vascular injury, in this case our patient’s HS. Pathology in our case revealed only “mild” changes suggestive of NRH, so the patient hasn’t yet developed portal hypertension. There are no cases in literature that document HS as a factor contributing to either of these disease states. Early suspicion and liver biopsy are necessary for prompt diagnosis and improved outcomes.

1373 A Rare Case of Biliary Obstruction in Autosomal Dominant Polycystic Kidney Disease

INTRODUCTION: Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most common genetic disease in adults. We present a rare case of biliary obstruction due to polycystic disease affecting the kidney and liver. CASE DESCRIPTION/METHODS: A 18 year old female patient with polycystic disease of the liver and kidney diagnosed in childhood, presented with new onset jaundice and abdominal pain radiating to the back. Initial labs suggested a predominantly cholestatic patter of liver injury with total bilirubin 3.1 mg/dl with a direct bilirubin of 2.3 mg/dl, aspartate aminotransferase 96 U/L, alanine aminotransferase 177 U/L, and alkaline phosphatase 237 international U/L. Lipase was noted to be 443 U/L. The patient did not exhibit signs of cholangitis and was started on intravenous fluids at 2 ml/kg/hr after a bolus of 2 L. The platelets were noted to be 123 with an INR of 1.3. A Magnetic Resonance Cholangiopancreatography showed near-complete replacement of hepatic, bilateral renal and pancreatic parenchyma with greater than 100 simple cysts. Also noted was dilatation of the common bile duct measuring up to 16 mm (Figure1). No internal filling defect was noted. An ERCP was performed. During endoscopy, multiple luminal “bulges” representing extrinsic compression of cysts were noted in the stomach and duodenal. A native ampulla was identified in the second portion and was displaced laterally by extrinsic luminal compression (Figure 2). Cholangiogram revealed dilated CBD and CHD with cystic dilations of the intrahepatic ducts more pronounced in the left lobe of the liver. There appears to be contrast seen in several liver cysts indicating possible communication of biliary tree with the cysts (Figure 3). We entertained the possibility of a choledochal cyst (4a). External compression of the intraduodenal CBD was the etiology of the obstruction and a 10 Fr × 10 cm plastic biliary stent was placed resulting in large volume of bile evacuating from the biliary tree. The placement of the biliary stent resulted in the normalization of total bilirubin to 0.5 mg/dl with, AST 23 U/L, ALT 24 U/L, and ALP 109 international U/L. We recognized the risk of cholangitis due to the stasis of contrast and provided Ceftriaxone 1 g IV intra procedure and Cephalexin once daily for 7 days. DISCUSSION: This patient with large number of hepatic cysts replacing the hepatic parenchyma and large renal cysts resulted in distal biliary compression in the intraduodenal portion. This patient is being considered for a liver kidney transplantation.

1328 Intrauterine Pregnancy Complicated by a Distal Common Bile Duct Mass: An Unlikely Diagnosis of Extrahepatic Cholangiocarcinoma With Intrahepatic Metastasis

INTRODUCTION: Cholangiocarcioma (CCA), a malignancy that originates from the epithelial cells of the biliary tree, is rare and often portends a poor prognosis with a survival rate of 5-10% at 5 years. CCA is even more infrequent during pregnancy with only a few reported cases. CASE DESCRIPTION/METHODS: A 37-year-old, 31-week pregnant female, presented to the ED with worsening epigastric pain for 3 months. She also had jaundice for several days. Her total bilirubin was 6.5, ALP was 631, ALT was 86, and AST was 80. Lipase was normal. CA 19-9 was elevated to 4649. She had an abdominal US that showed gallbladder sludge, 1.0 cm CBD, and coarse hepatic echogenicity. She underwent MRCP, which revealed CBD dilatation to 1.1 cm, leading up to a 1.7 cm segment of obstruction at the distal CBD, where there was an ill-defined heterogeneous soft tissue mass. Distal to the lesion, the CBD was normal in caliber, with slight prominence of the pancreatic duct at the pancreatic body. In addition, there were 2 hepatic lesions. ERCP was then done for further diagnostic workup. The CBD was deeply cannulated and injected with contrast, with brisk flow up to the hepatic ducts. The middle third of the CBD contained a 25 mm area of severe, localized stenosis, and the upper third of the CBD was dilated to 18 mm. Sphincterotomy was done, and a partially covered metal stent was placed in the CBD with good position and good bile flow. She then proceeded to undergo a CT-guided liver biopsy of the largest hepatic lesion, which ultimately showed moderately differentiated adenocarcinoma with extensive tumor necrosis and desmoplasia. Immunohistochemistry was diffuse and strongly positive for cytokeratin 7 and cytokeratin 19. Findings were all consistent with extrahepatic cholangiocarcinoma with intrahepatic metastasis. Oncology was consulted, who recommended starting a course of Abraxane, Gemcitabine, and Cisplatin, which she deferred until after childbirth. She continued to follow up with Oncology outpatient, but ultimately had uncontrollable disease. She passed away in inpatient hospice due to liver failure and polymicrobial bacteremia likely due to bowel leak and pneumobilia. DISCUSSION: CCA represents 3% of all gastrointestinal malignancies, and is extremely uncommon during pregnancy. Symptoms and labs can be similar to those seen in HELLP, obstructive cholestasis, and acute fatty liver of pregnancy. A full diagnostic workup is fundamental in pregnant patients presenting with abdominal pain, jaundice, and abnormal liver enzymes.

2153 Migrated Biliary Stent: When Everything Fails

INTRODUCTION: Migrating stents are a well-known complication of biliary stenting, occurring in 5-7% of patients undergoing ERCP. Numerous endoscopic devices are used to remove stents. However, we describe removal of a proximally migrated biliary stent using a cholangioscopy-guided retrieval basket. CASE DESCRIPTION/METHODS: An 86-year-old woman was admitted for septic shock, E. coli bacteremia and cholangitis. Urgent ERCP demonstrated two diverticuli with the major papilla inside one of them. Cholangiogram revealed CBD dilation to 8 mm with few small and large choledocholithiasis. A sphincterotomy and endoscopic dilation of the papilla were performed. However, due to duodenal spasms compromising visualization of the papilla and the associated sepsis, a 10-French by 9 cm plastic stent was placed in the biliary tree and the procedure was aborted. Repeat ERCP four weeks later showed the stent had migrated into the bile duct and was embedded behind the neck of the periampullary diverticulum. Multiple attempts to remove the stent using balloons, baskets, snares and Rat tooth forceps were unsuccessful. A repeat ERCP two weeks later showed the stent still embedded in the bile duct. A Spyglass cholangioscope was introduced into the bile duct and the retrieval basket was used to grasp the distal flap of the stent. Next, both the cholangioscope and stent were successfully withdrawn from the CBD. Finally, the bile duct was swept and remaining stones were removed. Re-inspection of the bile duct with the cholangioscope demonstrated no residual stones or biliary injury. DISCUSSION: Biliary stent migration is a relatively uncommon complication of ERCP. Multiple endoscopic tools have been described to retrieve migrated stents. These include retrieval balloons, baskets, and forceps. The newly developed Spyglass retrieval basket allows direct visualization and removal of the targeted object whether it is a stone or stent. This technique is a nice addition to our armamentarium for clearing the biliary tree. It could potentially lead to decreased radiation exposure and probably to a decrease in the number of procedures. The use of this device to remove migrated stents has not been previously reported. The main difficulty in our case was the suboptimal visualization once the basket was tightened around the stent as this blocks the view of the cholangioscope. Further advances are needed in order to develop devices that are able to close further away from the scope camera preserving cholangioscopic view of the biliary lumen.

1901 PEG Tube Induced Choledo-Duodenal Fistula: When to Expect the Unexpected

INTRODUCTION: PEG tube has become the modality of choice for providing access for long term enteral nutrition. Despite a good safety record, complications due to PEG dislodgment do occur. We present a case of PEG tube causing Choledo-duodenal fistula, presenting with Ascending Cholangitis. To the best of our knowledge, this unusual complication of PEG tube hasn't been described before. CASE DESCRIPTION/METHODS: 38 y.o.male with anoxic brain injury, PEG tube placed 6 months ago, presented for evaluation of Jaundice. Vitals were BP 145/108 | Pulse 135 | Temp 101.5 °F. On exam, patient had jaundice, abdomen was soft, Non tender, PEG tube was in the LUQ and Murphy’s sign was negative. Labs showed WBC 12 10X3 U/L, AST 46 U/L, ALT 131 U/L, TB 2.2 mg/dL, DB 1.1 mg/dL. CT abdomen and Pelvis revealed intrahepatic, extrahepatic and CBD dilatation to 1.2 cm, normal Pancreas. PEG tube with fluid-filled balloon was at the level of the pylorus or proximal duodenum. Small and large bowel were nondilated. The diagnosis of ascending cholangitis was made and ERCP was performed. ERCP showed the PEG tube balloon in the duodenum. It was repositioned into the stomach and the scope was advanced to the 2nd portion of the duodenum. There was a large white base ulcer at the duodenal sweep extending into the 2nd portion of the duodenum. Occlusion cholangiogram showed extravasation of the contrast from the distal CBD into the duodenal ulcer. There was a fistulous tract between the CBD and the ulcer. Sphincterotomy was made and a biliary stent was placed to heal the fistula. Biospy of the ulcer showed small intestinal mucosa with ulceration, fibrinoid exudates and no malignancy. Repeat ERCP 8 weeks later for stent removal, showed a chronic entero-biliary fistula. DISCUSSION: Our case is unique in that, this is the first CD fistula described in the literature as a complication of PEG tube presenting with ascending cholangitis. We hypothesize that the inflated balloon migrated into the duodenum due to gastric peristalsis and got incarcerated into the duodenum. 90% cases of CD fistula are due to impacted stone in the distal CBD. Other causes are Ampullary carcinoma or Cholangiocarcinoma. Based on our literature review, this is the only reported case of CD Fistula resulting from dislodged PEG tube causing direct pressure necrosis of the duodenal mucosa leading to erosion and fistulation with the distal CBD. Our case brings to light a new and potentially avoidable complication of PEG tubes.

1398 A Stone in the Wall: Extraction of an Embedded Choledocholithiasis in the Proximal CBD by Cholangioscopy

INTRODUCTION: Primary choledocholithiasis are stones formed in the common bile duct as opposed to secondary stones when they originate in the gallbladder and pass through. Symptomatic choledocholithiasis are usually managed by cholecystectomy but the CBD stones post cholecystectomy are not uncommon. The rate of recurrence of symptomatic CBD stone range from 4% to 24%. Having a stone impacted in the wall has never been reported before. CASE DESCRIPTION/METHODS: A 74-year-old man with a history of cholecystectomy for symptomatic cholelithiasis presented for one-year history or right upper quadrant colicky pain. He had recurrent CBD stones for four years before presentation. He underwent multiple endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stones removal multiple times. He had a CBD stent. Medical history is also relevant for atrial fibrillation on rivaroxaban and CAD on aspirin. Upon initial evaluation vitals were stable, physical examination was only relevant for RUQ abdominal tenderness. Imaging including computed tomography scan and an ultrasound revealed stable CBD dilation at 1.1 cm with no stones or intrahepatic biliary duct dilation. ERCP was performed with a cholangiogram showing multiple small filling defects in the CBD consistent with small stones. Sludge and stones were removed using a biliary stone extraction balloon. The duct was swept multiple times and no more stones were noted. The pain did not resolve. A repeat ERCP with a cholangioscopy using the spyglass system was performed. It revealed a normal CBD ductal walls, however closer to the bifurcation of the cystic duct, a small stone was noted; it was impacted in the wall. It was retrieved using a spyglass forceps. DISCUSSION: CBD stones are common after cholecystectomy. They are formed in the bile duct in situ and usually occur 12 months after surgery. Risk factors are the presence of multiple CBD stones and type 1 or 2 periampullary diverticulum. Cholangioscopy is sometimes needed as in our case to check for any stone that is impacted or left in the proximal common bile duct.

Hemobilia: an unusual and life threatening complication of laparoscopic cholecystectomy

Hemobilia though rare, occurs due to abnormal vascular and biliary communication established as a result of trauma, gallstones, neoplasms, inflammatory process and vascular disorders. It can rarely complicate a laparoscopic cholecystectomy as a result of hepatic artery injury, clip migration, clip erosion, diathermy and subsequent arteriobiliary fistula, or pseudoaneurysm eroding into the extra hepatic bile ducts. A 34 years female underwent laparoscopic cholecystectomy for cholelithiasis, suffered bile leak that settled on by 13th postoperative day, met with sudden right upper abdominal pain and hypovolemic shock on 15th postoperative day due to massive hemobilia arising out of rupture of pseudoaneurysm of the right hepatic artery into the biliary system. Urgent CT Angiography showed a large pseudoaneurysm of right hepatic artery branch with adjacent small collection, IHBR and CBD dilatation suggestive of hemobilia. Emergency CT guided trans-arterial hepatic artery embolization done to control hemobilia and save the patient. An immediate CT angiography for early diagnosis, in all postoperative laparoscopic cholecystectomy cases with suspicion of hemobilia due to an underlying hepatic artery pseudoaneurysm, followed by CT guided trans-arterial hepatic artery embolization forms the gold standard management in such patients.

Unusual cause of CBD Dilatation

Unusual cause of CBD Dilatation

A rare cause of upper gastrointestinal bleeding in pregnancy

A 29-year-old 11-week pregnant multigravida woman without previous medical history presentedwith sudden onset of hematemesis. This case illustrates the occurrence of a rare complication (rupture of pseudoaneurysm of right hepatic artery inside the biliary system), appearing as upper gastrointestinal bleeding in a pregnant woman. The cause of the rupture is presumably pregnancy-related. We would like to emphasize the presence of pseudoaneurysm of the hepatic artery as a rare cause of gastrointestinal bleeding in pregnancy.&#x0D; &#x0D; Figure 1 and 2 CTA showed a lobulated contour of saccular aneurysmal dilatation at proximal right hepatic artery, measured about 3.5x3.2x1.6 cm in size and 2.6 mm in neck width; pseudoaneurysm is likely. There is perianeurysmal heterogeneously hyperdense non-enhancing lesion which shows flip-flop phenomenon, measured about 5.5x6.1x5.5 cm in size; Partially thrombosed pseudoaneurysm at proximal right hepatic artery is likely. This lesion causes stretching of the common hepatic artery and portal vein. Hyperdenselesion with flip-flop phenomenon is also seen within dilated bilateral IHD, CHD, CBD and gallbladder; Contrast extravasation into CHD, CBD, 1st, 2nd, 3rd, 4th part of duodenum and jejunum is detected in portovenous phase. hemobilia is suggested.&#x0D;

Use of combined laboratory and ultrasonography results to select patients for biliary tract imaging or intervention: a retrospective cohort study.

To determine whether combined laboratory and ultrasonography results can be used to select patients for biliary tract imaging (BTI) or intervention. Despite ongoing research, selection of patients with suspected CBD stone (CBDS) for BTI or direct intervention without imaging is still a subject of debate. Patients aged≥18 with symptomatic gallstone disease (SGD) who underwent MRCP over 3 years (2014-2017) were divided into the following cohorts: Group A: Normal liver enzymes with normal CBD diameter; Group B: Normal liver enzymes with dilated CBD; Group C: Isolated rise of liver enzymes with normal CBD diameter; Group D: Isolated rise of liver enzymes with dilated CBD; Group E: Hyperbilirubinemia with normal CBD diameter; Group F: Hyperbilirubinemia with dilated CBD. Binary logistic regression models were constructed for analyses. Overall, 1022 patients were included. The frequency of CBDS was 7.2% in Group A; 3.8% in Group B; 6.3% in Group C; 22% in Group D; 24.2% in Group E; 47.4% in Group F. Hyperbilirubinemia with normal CBD (OR:1.52,P=0.010) and hyperbilirubinemia with dilated CBD (OR:5.12,P<0.001) independently predicted CBDS. Normal or isolated rise of liver enzymes with or without dilated CBD did not predict CBDS. Combined laboratory and ultrasonography had positive predictive value and negative predictive value of up to 47.37% and 100%, respectively. Patients with isolated rise of liver enzymes or hyperbilirubinemia with or without dilated CBD should undergo BTI prior to ERCP. Direct ERCP could be preserved for patients with high suspicion of CBDS where clinical features do not allow waiting for BTI.

Recurrence of choledocholithiasis following laparoscopic common bile duct exploration: a multicenter study and recurrent common bile duct stones

Introduction: According to updated guideline on the management of common bile duct stones(CBDS), In 10-20% of individuals with symptomatic gallstones, CBDS are estimated to be present. As well as after ERCP, recurrence of primary CBDS occurs after Laparoscopic common bile duct exploration (LCBDE). This study aimed to investigate risk factors for the recurrence of primary stones after LCBDE. Method: Patient who underwent LCBDE between January 2001 and December 2018 in 4 teaching hospitals in South,Korea were included. Patient, diagnostic, intra-operative and disease-related factors were collected from the patient charts. Specificically operation record, fluorocsopy and ERCP record were investigated, retrospectively. Primary outcome was recurrence. Multivariable logistic regression was performed to identifiy independent risk factors for CBDS recurrence. Result: 230 Patients were included. 31 Patients had recurrences. In univariable analysis CBD stone size (>9mm) (p=0.003), Multiple stone (≥2) (p=0.031), Stone size (≥1.5cm) (p=0.041), CBD diameter (≥12mm) (p=0.005) ,CBD dilatation (≥10mm) (p=0.02), Prior laparoscopic cholecystectomy history (p=0.002) were associated with Recurrence. After multivariable logistic regression, recurrences are associated CBD stone size (>9mm) (adjusted odds ratio [AOR] 4.28 ; 95% confidence interval [CI] 1.40-13.07 (p=0.011), CBD dilatation (≥10mm) [AOR] 5.85 ; 95% confidence interval [CI] 1.69-20.34 (p=0.005), Prior laparoscopic cholecystectomy history [AOR] 3.50 ; 95% confidence interval [CI] 1.31-9.35 (p=0.013). Conclusion: Stone size (more than 9mm), CBD dilatation (≥10mm), and prior cholecystectomy history are risk factors for CBDS recurrences and warrants close monitoring after operation.

Cysto-biliary communication (CBC) in hepatic hydatidosis: predictors, management and outcome

Background: Liver hydatidosis is a common health problem in endemic areas. Cystobiliary communication is the most common complication of liver hydatid.Methods: Cases of liver hydatid operated during the period June 2012 to July 2018 were retrospectively assessed. Patients diagnosed with cystobiliary communication (preoperatively, intraoperatively or postoperatively) were analysed. Demographics, laboratory tests were noted. Computed tomographic (CT) findings including size, location, Gharbi’s type, presence of intrahepatic biliary radical dilatation, CHD and CBD dilatation were noted. Intraoperative findings were noted. Postoperative outcomes and any intervention if done were noted. Results were analysed.Results: Around 108 patients with liver hydatid underwent surgical intervention. Of which 20 (18.5%) patients were found to have cystobiliary communication. Mean cyst size was 8cms. Location of cyst in segment IV and V commonly. 8 patients were diagnosed preoperatively by elevated bilirubin and alkaline phosphatase and on contrast enhanced computerized tomography. Out of 8, 4 patients underwent preop ERCP and stenting, followed by surgery and the other 4 underwent direct surgery with CBD exploration. 4 were diagnosed intraoperatively and the fistula site sutured. But 2 patients had postop biliary fistula which required postop ERC and stenting. Remaining 8 presented postoperatively with biliary fistula. Of 8 patients, 2 had major and 6 had minor fistulas. Postoperative mortality was 0%.Conclusions: Cystobiliary communication is more common in males with large cyst size, located in the central segments of liver close to biliary confluence, Gharbi type IV cysts. Timely diagnosis and appropriate management decrease the morbidity and mortality.

Hereditary Spherocytosis Complicated by Choledocholithiasis: Compounded Hyperbilirubinemia

Hereditary Spherocytosis (HS) has an estimated incidence of 1 in 5000 individuals in the United States and is inherited in an autosomal recessive pattern. Hyperbilirubinemia occurs as spherical RBCs are produced, which are culled rapidly from circulation by the spleen and hemolysis occurs, thereby leading to hyperbilirubinemia. Cholelithiasis, which manifests as pigmented bilirubin stones, is a common finding and may be a signal of an RBC disorder in mild HS. The incidence of choledocholithiasis in these patients is unclear. Jaundice can worsen many reasons including fatigue, cold exposure, emotional distress, or pregnancy. We present a case of choledocholithiasis in a patient with complicated HS. Our patient is a 20-year-old female with HS diagnosed as a child. Patient was recommended for splenectomy 4 years prior; however, mother refused due to risk of complications. U/S six years prior was negative for cholelithiasis. Patient presented to the hospital in winter with worsening jaundice, abdominal pain, nausea and vomiting for 5 days. Patient was noted to have an elevated bilirubin of 27.2 on admission, which trended up to 50.4. Fractionated bilirubin showed direct bilirubin of 36.4. Right upper quadrant ultrasound showed cholelithiasis with mildly dilated CBD and no evidence of choledocholithiasis. Given primarily direct hyperbilirubinemia, MRCP was obtained showing dilated CBD to 8mm with a large stone seen in the CBD. ERCP was performed with evidence of a filling defect in the distal CBD. Sphincterotomy with balloon sweeps were performed and yielded a large pigmented stone. Patient bilirubin improved to 17.9 prior to cholecystectomy. Unfortunately, patient had a gastric perforation during splenectomy and cholecystectomy given multiple accessory spleens and complicated surgical procedure and subsequently passed away. Our case is a rare example of complicated HS as splenectomy was previously recommended and is the definitive treatment for HS. Choledocholithiasis in patients with HS has not been clearly defined. One study in India on 70 patients showed that 36.8% of patients with HS diagnosed had cholelithiasis or choledocholithiasis but did not clearly differentiate between the prevalence of choledocholithiasis. Literature review only yielded case reports of choledocholithiasis in patients with HS. Our case serves as an example of the difficulty in diagnosing choledocholithiasis as our patient had multiple risk factors for worsening jaundice.2109_A Figure 1. ERCP demonstrating filling defect at the distal CBD (arrow) suggestive of choledoholithiasis2109_B Figure 2. Endoscopic view during ERCP demonstrating large bilirubin pigmented stone extracted from balloon sweeps

Afferent Loop Syndrome Masquerading as Recurrent Acute Pancreatitis

Introduction Afferent loop syndrome (ALS) is a rarely described complication following gastric-bypass surgery and the creation of gastro-jejunostomy. We present a case of this disorder mimicking recurrent acute pancreatitis. Case presentation A 67 yr old Caucasian F underwent Roux-en-Y gastric bypass in 2012. Initially had good weight loss and no post-operative complications. In 2017, began to develop recurrent episodes of epigastric/RUQ pain, N/V. CT scan showed cholelithiasis and internal hernia. Labs were all normal, including CBC, hepatic function, and lipase. She underwent cholecystectomy and hernia repair. Patient continued to have pain, but this time with lipase greater than 3 times the upper limit of normal concerning for pancreatitis. MRCP was normal except mildly dilated CBD, however CT showed dilated loops of small bowel in pelvis. Repeat surgical exploration was performed with extensive lysis of adhesions. Patient continued to have intermittent pain with elevation of lipase concerning for pancreatitis. Autoimmune pancreatitis was ruled out. Given dilated CBD and increasing ALP, there was concern for SOD type 1. Lap assisted ERCP was performed which showed papillary stenosis and was treated with dual sphincterotomy. Following ERCP patient did well for about 1 month until similar pain led to repeat hospitalization. Lipase was elevated as well. CT showed significantly dilated duodenum and remnant stomach concerning for afferent loop syndrome. Patient underwent revision of jejunostomy with biliopancreatic limb being re-anastomosed 10cm distal to prior site with 10cm long anastomosis to prevent recurrence. Following this procedure patient had complete resolution of symptoms. Discussion ALS is a consequence of partial or complete obstruction of the gastrojejunostomy along the jejunal portion of the afferent limb. Passage of food and gastric secretions through the gastrojejunostomy and into the efferent loop triggers the release of secretin and cholecystokinin, which in turn stimulate secretion of upto 1-2 L of pancreatic and biliary secretions into the afferent loop each day. Symptoms are usually caused by increased intraluminal pressure and distention due to accumulation of these secretions in an obstructed afferent limb. This can present as obstructive jaundice, ascending cholangitis, and pancreatitis. Our case serves to highlight the importance of taking a multi-disciplinary approach to these complicated patients with ongoing abdominal pain.1384_A.tif Figure 1: No Caption available.1384_B.tif Figure 2: No Caption available.