Dilated CBD Research Articles

S1699 Biliary Fascioliasis Presented With Recurrent Pruritus

Introduction: Fascioliasis is a waterborne disease caused by Fasciola Hepatica (FH), mainly involves the hepatobiliary and has 2 phases of manifestation. The hepatic phase typically occurs 6-12 weeks after ingestion, characterized by right upper quadrant abdominal pain, elevated liver enzyme, and eosinophilia. Adult flukes migrate to biliary tracts during the biliary phase and can be asymptomatic or present with biliary obstruction, cholangitis, and pancreatitis. In the endemic areas, FH should be considered for idiopathic biliary obstruction with atypical symptoms. Here, we report a 36 y/o male from Iron who presented with recurrent pruritus and was found to have FH which was removed by ERCP. Case Description/Methods: A 36-year-old man from Iran was initially admitted due to 2 years history of occasional vague abdominal pain. The patient also had recurrent non-rash pruritus not responding to medication. Past medical history was unremarkable. The laboratory test were all normal except for elevated CRP and eosinophil percentage (3%). Upper and lower endoscopy were all negative. Abdominal US showed dilated CBD without any significant findings. Follow-up EUS showed dilated CBD of 16mm with some filling defects and 2 live parasites (Figure). EUS-guided ERCP was done with CBD cannulation and biliary stent placement. 10mg/kg of triclabendazole was administered as a single dose 4 days after the procedure. Another ERCP was performed later for biliary stent removal and live trematode extraction without any complication. During one month follow up, the patient was free of symptoms with back to normal CRP and eosinophil percentage. A 1-year EUS follow-up showed normal CBD without any stone, sludge, or lesion. Discussion: Humans can be accidental hosts for FH with variable symptoms, such as urticaria, cough, dyspnea, cholangitis, biliary obstruction, and cholecystitis. Stool microscopy in addition to imaging studies is always used for diagnosing. The first-line treatment is 10mg/kg triclabendazole every 12 hours for 2 doses. However, due to the high risk of biliary obstruction and related complications, endoscopic clearance is mandatory in cases like this. Biliary sphincterotomy and extraction of flukes by balloon extraction or basket are very effective and safe interventions. In a patient suffering from recurrent pruritus not responding to medications and eosinophilia, abdominal US should be considered for FH, especially in an endemic region of the world.Figure 1.: EUS Showing the Parasite with the arrow pointing to the location.

S1926 A Young Female With Acute Cholangitis Due to Type IVa Choledochal Cyst With an Undifferentiated Spindle and Giant Cell Carcinoma Hiding Inside

Introduction: This patient is being presented to demonstrate the rarity and severity of extrahepatic biliary cystic masses as the primary etiology of acute cholangitis in a young patient, after failing endoscopic stent placement. Case Description/Methods: A 29-year-old female with no medical history presented with 2 days of sharp, epigastric pain radiating to the back associated with fevers and non-bilious vomiting. Patient’s exam noted scleral icterus and abdominal exam showed tenderness to palpation in the right upper quadrant. Labs showed a WBC of 26,300, AST of 114, ALT of 289, ALP of 343 IU/L, and total bilirubin of 9.76 mg/dL. Computed tomography (CT) of the abdomen showed dilated proximal extrahepatic CBD with a large complex cystic mass in the porta hepatitis measuring 10 cm x 9 cm x 8 cm and this was contiguous with gallbladder and proximal common bile duct with mass effect on duodenum and pancreatic head concerning for Type I choledochal cyst. An ERCP showed a significantly dilated CBD with cystic dilation and balloon sweep with 9-10-12 mm balloon catheter was performed with passage of a small stone and pus. Two plastic stents 10 Fr x 7 cm and 10 Fr x 9 cm were placed with appropriate bile drainage. Fevers continued and total bilirubin increased to 14.2 mg/dL and ALP reached 535 IU/L, therefore patient was taken for laparoscopy which showed large choledochal cyst intimately involved with the head of the pancreas and duodenum, necessitating a Whipple procedure for distal margin. Proximal margin entered the left and the right hepatic ducts, consistent with a type IVa choledochal cyst. Anatomic pathology of the 7.0 cm x 6.0 cm x 3.0 cm mass in the cyst showed an undifferentiated spindle and giant cell carcinoma, confined to the bile duct histologically, with lymphovascular and perineural invasion present. There was no gallbladder involvement and 25 lymph nodes were negative for malignancy. The patient improved and was discharged to home after extended recovery (Figure). Discussion: Undifferentiated carcinoma of the extrahepatic biliary system is extremely rare and has been previously found on middle-age to elderly patients. Diagnosis of undifferentiated carcinoma of the extrahepatic biliary system is difficult because the exact diagnosis cannot be determined prior to surgical resection. Patients with undifferentiated carcinoma of the extrahepatic bile duct may have a relatively better prognosis due to the early appearance of jaundice, compared to those with gallbladder involvement.Figure 1.: MRCP of Type IV choledochal cyst

S2890 A Case for Endoscopic Ultrasound-Directed TransGastric ERCP (EDGE) Procedure: Removal of Choledocholithiasis in Gastric Bypass Patient

Introduction: Due to rise in obesity, there has been an increased number of gastric bypass surgeries. Around 36% morbidly obese patient develop cholelithiasis or choledocholithiasis (CDL) in their lifetime. Due to the anatomy, a conventional Endoscopic Retrograde Cholangio Pancreatography (ERCP) is often challenging and not possible. We present a case of an altered anatomy ERCP in a patient with CDL and Roux-en-Y gastric bypass (RYGB) who underwent Endoscopic ultrasound Directed trans-Gastric ERCP(EDGE) procedure. Case Description/Methods: A 69-year-old female with a history of RYGB admitted for Hartmann’s procedure. During the hospitalization, she complained of RUQ pain and CT abdomen showed a distended gallbladder with cholelithiasis and CBD dilation of 8.3mm; MRCP confirmed five or more CDL. A traditional attempt at an ERCP using a pediatric colonoscope was unsuccessful in reaching the papilla. She underwent cholecystectomy with an intraoperative cholangiogram re-demonstrating the CDL. Options were to do a laparoscopy assisted ERCP v/s double balloon assisted ERCP v/s EDGE. Due to already multiple surgeries patient opted for EDGE procedure. For stage 1 of the EDGE, the excluded stomach was identified under EUS and punctured using a 19-gauge-needle followed by a radiocontrast dye injection into the excluded stomach confirmed under fluoroscopy. Subsequently, a guidewire was advanced through the needle into the pylorus and duodenum to verify the patency of pylorus. After confirming access to the excluded stomach, a 20 x 10 mm (AXIOSTM) lumen apposing metal stent (LAMS) was placed and a gastro-gastric fistula between the gastric pouch and the excluded stomach was formed. The lumen of the stent was subsequently dilated using a CRE balloon confirming the direct visualization of the gastric rugae. (Figure). The LAMS was left for 4 weeks for the tract to mature. Stage 2 of the EDGE procedure was then completed by passing the duodenoscope through the LAMS and completion of the traditional ERCP followed by removal of the LAMS. Overall patient did well. Discussion: EDGE is a minimally invasive EUS guided technique for doing an ERCP in patients with RYGB. Comparison studies have shown EDGE to have similar or better technical success when compared to laparoscopy-assisted ERCP and balloon Enteroscopy-assisted ERCP. Due to the high technical skill required in doing an EDGE, it is best advisable to offer this at institutions where a trained advanced endoscopist well versed with a therapeutic EUS is available.Figure 1.: A: EGD showing gastric pouch post-RYGB B: EUS suggests decompressed excluded stomach C: Injecting contrast into the excluded stomach - to make cystic cavity D: 20 x 10 mm(AXIOS) lumen apposing metal stent placement E: CRE Baloon dilation of LAMS F: Confirmed visualization of excluded gastric mucosa - gastrogastric fistula

EP-341 Haemorrhagic Cholecystitis with cystic artery pseudo-aneurysm

Abstract Introduction Haemorrhagic cholecystitis and cystic artery pseudo-aneurysm (CAP) are two very uncommon causes of right upper abdominal pain. However, the development of haemorrhagic cholecystitis induced by ruptured cystic artery pseudo-aneurysm and haemobilia are extremely rarely documented with few occurrences documented in the literature. Case presentation A 80year-old frail patient was admitted with RUQ pain, deranged LFTs and melaena. She had known gall stones, hypertension, chronic kidney disease and fibromyalgia. She demonstrated localized tenderness in the right abdomen and bloods showed a significant drop in haemoglobin which required blood transfusion. Abdominal ultrasound showed cholecystitis and MRCP showed CBD dilatation with no choledocholithiasis. She was found to have haemorrhagic cholecystitis and CAP along with a cholecysto-colonic fistula on triple phase liver CT. The patient underwent urgent embolization of the CAP and remained clinically stable. She was discharged home with a plan of further review before consideration for cholecystectomy. Clinical discussion Haemorrhagic cholecystitis and CAP are rare. Clinical suspicion is warranted to diagnose the case – the combination of features of cholecystitis with acute anaemia should raise the suspicion. Diagnosis is made primarily by pathognomonic findings on appropriate phase of CT and US imaging. Prompt diagnosis and management is essential in preventing mortality and/or significant morbidity. Conclusion A rare consequence of intra-biliary bleeding due to ruptured CAP leading to haemorrhagic cholecystitis is a potential differential diagnosis in patients presenting with right upper abdominal pain and haemoglobin drop. Close liaison with radiologist is warranted to organise appropriate investigation for diagnosis and successfully manage the condition.

Role of Magnetic Resonance Cholangiopancreatography (MRCP) in Evaluation of Pancreaticobiliary Pathologies and Correlation with Ultrasound Findings

Background- In this prospective study, we evaluated the role of magnetic resonance cholangiopancreatography (MRCP) as an imaging modality for identification and characterization of various pancreaticobiliary pathologies and to correlate MRCP findings with ultrasound (USG) findings. Methodology–This study was carried out as an observational study in Department of Radiodiagnosis, GMC Bhopal, for a study period of 20 months on patients suspected with pancreaticobiliary pathologies reporting for ultrasound examination. MRCP was performed following Ultrasound imaging (USG) with subsequent comparison of findings. Results- The sensitivity, specificity and diagnostic accuracy of ultrasound in detection of CBD dilatation were 86.21%. 100% and 92% respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of ultrasound in detection of intrahepatic biliary radicle (IHBR) dilatation was 81.97%. 97.44%. 98.04%. 77.55% and 88% respectively. The sensitivity of USG for identification of benign lesions was 93.55% whereas that for malignant lesions was 96.15%. Overall, diagnostic accuracy of USG for identification of benign and malignant lesions was 84% and 87% respectively. Conclusion– Although abdominal ultrasound continues to serve as a screening tool for detection of pancreaticobiliary pathologies and allows for differentiation between surgical and non-surgical causes of obstructive jaundice, the in-depth characterization of lesions as provided by magnetic resonance imaging (MRI) with MRCP suggests that it serves as an indispensable adjunct to endoscopic retrograde cholangiopancreatography (ERCP). MRCP with MRI serves as an accurate and non-invasive, non-ionizing imaging method for evaluation of biliary anatomy and pathology especially in cases of obese patients where ultrasound results are compromised.

Comparison of Ultrasound and MRI Findings in the Evaluation of Pelvic masses/lesions with Histopathological Correlation in Female Patients

Background- In this prospective study, we evaluated the role of magnetic resonance cholangiopancreatography (MRCP) as an imaging modality for identification and characterization of various pancreaticobiliary pathologies and to correlate MRCP findings with ultrasound (USG) findings. Methodology–This study was carried out as an observational study in Department of Radiodiagnosis, GMC Bhopal, for a study period of 20 months on patients suspected with pancreaticobiliary pathologies reporting for ultrasound examination. MRCP was performed following Ultrasound imaging (USG) with subsequent comparison of findings. Results- The sensitivity, specificity and diagnostic accuracy of ultrasound in detection of CBD dilatation were 86.21%. 100% and 92% respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of ultrasound in detection of intrahepatic biliary radicle (IHBR) dilatation was 81.97%. 97.44%. 98.04%. 77.55% and 88% respectively. The sensitivity of USG for identification of benign lesions was 93.55% whereas that for malignant lesions was 96.15%. Overall, diagnostic accuracy of USG for identification of benign and malignant lesions was 84% and 87% respectively. Conclusion– Although abdominal ultrasound continues to serve as a screening tool for detection of pancreaticobiliary pathologies and allows for differentiation between surgical and non-surgical causes of obstructive jaundice, the in-depth characterization of lesions as provided by magnetic resonance imaging (MRI) with MRCP suggests that it serves as an indispensable adjunct to endoscopic retrograde cholangiopancreatography (ERCP). MRCP with MRI serves as an accurate and non-invasive, non-ionizing imaging method for evaluation of biliary anatomy and pathology especially in cases of obese patients where ultrasound results are compromised.

A retrospective analysis of magnetic resonance cholangiopancreatography investigating gallstones in a contemporary surgical setting.

BackgroundsThe New Zealand Public Health System operates in a resource limited environment. Pre‐operative investigation of choledocholithiasis (CDL) is variable. Protocol driven practice has improved patient outcomes and cost‐effectiveness. The aim is to explore risk stratification for CDL and specific thresholds for accessing magnetic resonance cholangiopancreatography (MRCP) in this contemporary setting.MethodsAll adult (16+ years) acute inpatient MRCP requests for gallstone work‐up between 1 Jan 2018 and 2031 Dec 2019 at Dunedin Hospital were included. Patients with characteristics not in fitting with an acute symptomatic examination were excluded. Receiver operating characteristic curves were estimated for bilirubin versus MRCP positive by the presence/absence of dilated ducts, indication and American Society of Gastrointestinal Endoscopy (ASGE) risk grouping.ResultsA 106 patients were included. Mean bilirubin at presentation and time of MRCP, 47 versus 28 μmol/L, respectively. MRCP confirmed CDL in 39 (37%) patients. 38 (97%) had biochemical changes with choledocholithiasis. 21 (40%) with CBD dilation had ductal stones versus 18 (34%) with normal ducts. ASGE risk stratification showed 36 (34%), 66 (62%) and 4 (4%) were high, intermediate and low risk, respectively. Of these groups 44%, 35% and 0% had CBD stones on MRCP, respectively. Combination thresholds involving duct size and bilirubin can yield negative predictive values >90%, substantially reducing MRCP load.ConclusionsMRCP requests can be triaged to maximize stones detected without overly increasing the rate of missed duct stones whilst protecting the limited MRI and ERCP resources. International thresholds and risk stratification alone may not be applicable in our resource limited environment.

NON-INVASIVE IMAGING OF CHOLANGIO-PANCREATIC DISEASES USING MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY AND CORRELATION WITH ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

NON-INVASIVE IMAGING OF CHOLANGIO-PANCREATIC DISEASES USING MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY AND CORRELATION WITH ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Frequency of Clinical Symptoms in Post Cholecystectomy Syndrome Patients our Hospital Experience: A Cross-Sectional Study

Aim: To determine the frequency of different clinical symptoms in (PCS) Post Cholecystectomy Syndrome patients, at a secondary care facility Study Design: A cross-sectional study Place and Duration: This study was conducted at Liaquat University of Medical Health Sciences Jamshoro, Pakistan from May 2020 May 2021. Methodology: For the purpose of this study, 100 patients were selected. Only those individuals were selected who qualified against an inclusion criterion which was set based on the patients’ history of cholecystectomy. For this purpose, a questionnaire was made. The patients that were selected had to go through CT (computed tomography) scans and sonographic tests. Blood testing was also done and sera were prepared for in-depth laboratory tests. Data from the research were analyzed by using SPSS version 19. Results: Most common clinical symptom after post-surgery was right upper quadrant pain (114 patients). Epigastric discomfort was present in 97 patients. Fever was third in line (73 patients) with jaundice being fourth (23 patients). Abdominal tenderness (19 patients) was followed by bile leakage (7 patients), fluid in the peritoneal region (19 patients), CBD dilation (39 patients), recurrent stone in CBD (12 patients), retained stone in CBD (19 patients), dysfunctioning of Oddi sphincter (37 patients) and remnants of the cystic duct stump was present in 41 patients. Conclusion: The results of this study show that post cholecystectomy symptoms and conditions vary among patients and all of them need to be kept in while proposing proper follow-up treatment Keywords: post cholecystectomy syndrome, bile leak, sonography, CT scan

Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis

Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances. We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed. 2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114min vs 79min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independentrisk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC. Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.

Current Safety and Feasibility of ERCP in Management of Early nd Late Post Liver Transplant Biliary Complications

Background: Biliary complications after living donor liver transplantation (LDLT) represent the most challengeable burden. Aim: We aimed to study safety and efficacy of the ERCP procedures in liver transplant patients. We additionally aimed to study the clinical and biochemical changes before and after ERCP. Patients & Methods: This was retrospective study: between April 2014 and December 2015, we reviewed medical records of 108 patients with LDLL. ERCP was indicated in 30 patients (28 males) at the National Liver Institute-Menoufia University hospital. Results: Stricture was the highest reported complication occurred in (56.6) %followed by leakage in (53.3), % stone formation in (6.6) %, dilatation of CBD (SOD) and cholangitis in (3.3) % for each. The frequencies of complication in every patient were: 1, 2 & > 2 complications in 21, 7 & 2 respectively. Timing of complications: in . 3 months 16 patients, 17 patients in 4-12 month, 3 patients>12 months. Post ERCP complications: mild pancreatitis and GIT bleeding in one patient for each, there were significant changes regarding all liver profile after LDLT before any complication and on the day of presentation (during complication) and one month after ERCP (p<0.05). Conclusion: ERCP was safe and effective in treatment of post liver transplant biliary complications.

O-BN06 A Proposed Difficulty Grading System for Laparoscopic Bile Duct Exploration. Benefits to Practice and Research

Abstract Background A gap remains between the mounting evidence for single session management of bile duct stones and the obstacles to wider adoption of this approach. The practice of laparoscopic bile duct exploration (LCBDE) is limited not only by the availability of training opportunities and adequate equipment but also by the perception that the technique is difficult and requires a high skill-set. The aim of this analysis is to compare the preoperative and operative characteristics and the postoperative outcomes in easy vs. difficult LCBDE in a large consecutive series, according to a proposed 5 grade classification. Methods 1326 LCBDEs were graded according to the location, number and size of ductal stones, retrieval techniques used, utilisation of choledochoscopy and specific biliary pathologies encountered. The cohort was divided into two groups: easy (Grades I A&amp;B, and Grade II A&amp;B, requiring transcystic or transductal exploration for up to 15 stones the largest being 15mm) and difficult (Grades III A&amp;B, for over 15 stones or intrahepatic stones of any size needing transcystic choledochoscopy, IV and V with Mirizzi Syndrome, impacted stones, and ducts needing stenting, conversion or bilioenteric anastomosis). Various outcome parameters were compared. Results Age, sex, obesity and previous biliary admissions had no effect on operative difficulty. Emergency admission, obstructive jaundice, previous ERCP and dilated CBD were predictive of difficult explorations. 78.3% of patients with acute cholecystitis or pancreatitis, 37 % of jaundice and 46% of cholangitis had easy explorations. Transcystic stone retrieval was possible in 77.7% of easy explorations and choledochotomy required in 62.3% of difficult explorations (vs. 33.6% in the whole series). Choledochoscopy was utilised in 23.4% of Grades I&amp;II vs. 98% in difficult explorations. As expected more biliary drains, stenting, bilio-enteric anastomosis, conversions, operative time, biliary-related complications, hospital stay, readmissions and retained stones increased with difficulty. Grades I&amp;II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V, the median presentation to resolution interval increasing from 1 to 3 weeks. There were 2 deaths in difficulty Grade V and one in Grade IIB. Conclusions Difficulty grading of LCBDE is a useful tool of predicting outcomes. It facilitates comparison between studies and fair assessment of training. LCBDEs are easy in 72% and of these 77% can be completed transcystically. It is hoped this will encourage more units to adopt single session management of bile duct stones through establishing referral protocols, developing and refining the skills through training and acquiring the necessary equipment.

Validation of choledocholithiasis predictors from the "2019 ASGE Guideline for the role of endoscopy in the evaluation and management of choledocholithiasis."

Identifying patients likely to have CDL is an important clinical dilemma because endoscopic retrograde cholangiopancreatography (ERCP), carries a 5-7% risk of adverse events. The purpose of this study was to compare the diagnostic test performance of the 2010 and 2019 ASGE criteria used to help risk stratify patients with suspected CDL. Consecutive patients evaluated for possible CDL from 2013 to 2019 were identified from surgical, endoscopic, and radiologic databases at a single academic center. Inclusion criteria included all patients who underwent ERCP and/or cholecystectomy with intraoperative cholangiogram (IOC) for suspected CDL. We calculated the diagnostic test performance of criteria from both guidelines and compared their discrimination using the receiver operator curve. Univariate and multivariate analysis was used to identify the strongest component predictors. 1098 patients [age 57.9 ± 19.0 years, 62.8% (690) F] were included. 66.3% (728) were found to have CDL on ERCP and/or IOC. When using the 2019 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 65.8, 78.9, 86.3, 54.1, and 70.4%, respectively. Using the 2010 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 50.5, 78.9, 82.5, 44.8, and 60.1%, respectively. The AUC for high-risk criteria using the 2019 guidelines [0.726 (0.695, 0.758)] was greater than for the 2010 guidelines [0.647 (0.614, 0.681)]. The key difference providing the increased discrimination was the inclusion of stones on any imaging modality, which increased the sensitivity to 55.0% from 29.1%. Not including CDL on imaging or cholangitis, a dilated CBD was the strongest individual predictor of CDL on multivariate analysis (OR 3.70, CI 2.80, 4.89). Compared to 2010, the 2019 high-risk criterion improves diagnostic test performance, but still performs suboptimally. Less invasive tests, such as EUS or MRCP, should be considered in patients with suspected CDL prior to ERCP.

S1597 A Rare Presentation of Lemmel’s Syndrome as Acute Cholangitis With Acute Pancreatitis

Introduction: Duodenal diverticula are most commonly found in the second part of the duodenum adjacent to the ampulla of Vater. Periampullary diverticula (PAD) are extraluminal pseudo-diverticula lacking a mucosal layer. Although typically asymptomatic, they can rarely cause pancreaticobiliary obstruction. Obstructive jaundice can develop secondary to PAD without choledocholithiasis, a rare phenomenon called Lemmel’s Syndrome. We report a rare case of Lemmel’s syndrome presenting not only with acute cholangitis but also with concurrent pancreatitis, successfully treated with ERCP. Case Description/Methods: An 83-year-old female presented with upper abdominal pain, nausea, diarrhea, and rigors. She is s/p cholecystectomy and labs revealed AST 688 U/L, ALT 305 U/L, Alkaline Phosphatase 201 U/L, total bilirubin 3.4 mg/dL, lipase 968 U/L, and lactate 2.9 mmol/L. An abdominal CT scan showed severe dilation of the common bile duct of 2.1 cm with edematous appearance of the pancreatic head, findings of acute pancreatitis, and a large duodenal diverticulum adjacent to the pancreatic head (Fig 1). Her hospital course was complicated by gram negative bacteremia, concerning for acute cholangitis. MRCP confirmed marked dilation of the common bile duct extending to the Ampulla of Vater with a large periampullary diverticulum, without choledocholithiasis or mass lesions (Fig 2). The patient underwent ERCP which revealed a large duodenal diverticulum compressing the distal bile duct, treated with biliary sphincterotomy and stent placement (Fig 3-4). She showed gradual clinical improvement with this endoscopic approach and was discharged home with subsequent follow up for stent removal performed 6 weeks later. Discussion: Although common among duodenal diverticula, PAD are rarely symptomatic. The underlying pathogenesis remains unclear but is believed to be related to mechanical obstruction, inflammation, and fibrosis. Lemmel’s syndrome can be mistaken for pseudocysts, necrotic collections, periampullary tumors, and pancreatic head neoplasms. Physicians should have a high index of suspicion for Lemmel’s syndrome in patients with large symptomatic PAD, which although commonly presents as biliary obstruction causing acute cholangitis, can rarely also cause pancreatic obstruction leading to pancreatitis, as seen in our patient. Timely diagnosis and endoscopic treatment of Lemmel’s syndrome can be effective in the treatment of acute cholangitis and pancreatitis.Figure 1.: CT scan showing CBD dilation with large periampullary diverticulum.Figure 2.: MRI showing dilated CBD and PD with distal large periampullary diverticulum.Figure 3.: Endoscopic view of large periampullary diverticula with intradiverticular papilla seen on ERCP.Figure 4.: Fluoroscopic view of dilated CBD as a result of Lemmel’s syndrome.

S1581 Hemobilia From an Unlikely Culprit: A Case of a Ruptured Pseudoaneurysm

Introduction: Hemobilia, or bleeding from the hepatobiliary tract, is a rare cause of GI bleeding and jaundice. Most cases of hemobilia are iatrogenic secondary to hepatobiliary interventions, however, trauma and malignancy also represent a major source. We present a case of hemobilia secondary to a hepatic artery pseudoaneurysm, in the setting of acute cholecystitis and metastatic liver disease. Case Description/Methods: A 67-year-old man presented with 3 days of RUQ abdominal pain radiating to the epigastrium. On arrival, he was tachycardic, afebrile, and normotensive. He had RUQ tenderness and icterus. Laboratory findings were significant for leukocytosis, anemia, transaminitis, elevated alkaline phosphatase, and hyperbilirubinemia. An ultrasound of the abdomen was suggestive of calculous cholecystitis and a dilated CBD of 0.8 cm. He underwent a EUS which revealed a dilated CBD with heterogeneous mater. An ERCP showed altered blood at the ampulla. A sphincterotomy was performed and a large blood clot was extracted from the CBD via balloon sweeps. Two plastic stents were then placed for drainage after which brisk arterial bleeding was noted. Urgent angiography revealed evidence of a ruptured pseudoaneurysm arising from the anterior division of the right hepatic artery near segment 8 of the liver. Successful coil embolization was performed. A CT scan of the abdomen revealed rectal thickening and hypoenhancing liver lesions suggestive of metastatic disease. On flexible sigmoidoscopy, a fungating, partially obstructing rectal mass was seen, biopsies of which were positive for invasive adenocarcinoma. Cholecystitis confirmed on HIDA scan was treated conservatively with antibiotics. He was subsequently discharged and started on chemotherapy as an outpatient. He is now planned for a repeat ERCP with stent exchange. Discussion: Hemobilia can masquerade as biliary stones on EUS. Management includes early diagnosis, identification of the source of bleeding, achieving hemostasis, and relieving the obstruction. Transcatheter arterial embolization is preferred if there are any signs of arterial extravasation. Biliary obstruction can be relieved with ERCP and stent placement. In the presence of underlying malignancy, infiltrative disease and its surrounding vascular friability are often implicated. However, a benign etiology should not be overlooked as illustrated in our case. Cholecystitis leading to severe inflammation of the gallbladder bed can cause adjacent arterial wall degeneration and pseudoaneurysm formation.Figure 1.: (A) Superselective catheterization of the right hepatic artery and angiography demonstrating evidence of 1.2 x 0.9 cm pseudoaneurysm/contained perforation, arising from a suspected proximal segment 8 arterial branch. (B) Endoscopic ultrasound demonstrating a dilated common bile duct up to 12 mm, filled with heterogeneous material. The gallbladder wall appears thickened. (C) CT abdomen with contrast showing multiple hypoenhancing liver lesions within the right and left lobes. Surgical coils within the right lobe of the liver consistent with a recent embolization procedure. Common bile duct stent in place, and small foci of pneumobilia. (D) ERCP images showing blood clots protruding from the ampulla. After balloon sweeps and sphincterotomy, two 10 Fr by 7 cm plastic stents were placed in the CBD.Table 1.: Laboratory Values from Admission and Discharge day.

S2141 Endoscopic Resection of Intraductal Papillary Neoplasm of the Bile Duct

Introduction: Intraductal papillary neoplasm of the bile duct (IPNB) is a neoplasia variant considered the biliary equivalent of IPMN of the pancreas. Characterized by a papillary growth with or without mucin hypersecretion, it can progress to invasive cholangiocarcinoma and develops along both the intra and extrahepatic bile ducts (BD). Case Description/Methods: A 79-year-old male with a PMH of anemia, CVA, CHF, CAD, CKD, Afib on anticoagulation was assessed for chronic anemia with CT of the abdomen. A 13mm CBD dilation was found, and this was further assessed with MRI which revealed choledocholithiasis and nodular enhancement of the ampulla. With these findings an ERCP was performed, stones were removed from the CBD and a polypoid mass was seen distally in the CBD and a plastic stent was placed, biopsy from the mass showed IPNB with low grade dysplasia. Another ERCP (Figure 1-B, 1-C) was performed for further assessment, during cholangioscopy the lesion was seen on the distal CBD. Since the patient was deemed a poor surgical candidate, attempts to endoscopically resect the lesion was made. Prior sphincterotomy was extended and the polypoid mass spontaneously extruded into the intestinal lumen (Fig 1-D), then the tumor was resected in a piecemeal fashion with a cold snare, followed by a repeat cholangioscopy, with no apparent tissue remaining (Fig 1-E). A fully covered metal stent was placed in attempts to cause pressure necrosis of any remaining tissue (Fig 1-F). Repeat ERCP with cholangioscopy for surveillance is pending. Discussion: IPNB is a rare tumor that presents most commonly with abdominal pain, jaundice, and/or cholangitis, or as an asymptomatic intraductal mass with BD dilation. Commonly affecting ages 50-70 with a marginal male predominance, the highest incidence is reported in Eastern countries where risk factors such as hepatolithiasis, choledocholithiasis, and parasitic infections of the BD are common. The WHO classification differentiates IPNB as low, intermediate, or high-grade intraepithelial neoplasia and IPNB associated with invasive carcinoma. IPNB mandates treatment irrespective of the presence of malignancy, otherwise the tumor growth can provoke obstructive jaundice which can lead to further morbidity. Surgical resection is considered for tumors without metastasis. Tumors without carcinoma and limited superficial spread can have limited surgical resection aimed to preserve organ function. We describe a case of a distal IPNB with limited superficial spread treated endoscopically.Figure 1.: A) Polypoid mass and plastic stent in the distal CBD during MRCP. B) Polypoid mass in the distal CBD during cholangiogram. C) Ampullary region showing previously placed plastic stent. D) Distal IPNB better visualized after extended sphincterotomy. E) Cholangioscopy after piecemeal resection of IPNB F) Stent placement after resection.

S3375 Utility of Double Balloon Enteroscopy in Patients with Orthotopic Liver Transplant with Hepaticojejunostomy: Observational Study

Introduction: Double Balloon enteroscopy ( DBE ) in patients with altered anatomy can be technically challenging, however offers both diagnostic and therapeutic useful modality. We describe the patients with h/o orthotopic liver transplant with hepatic jejunostomy who underwent DBE with regards to indications, and readmissions Methods: From a large database of patients who underwent DBE, patients with h/o orthotopic liver transplant with hepatic jejunostomy were identified and their charts were reviewed. Results: We found total of 9 DBE procedures performed on 6 patients (males = 5, female = 1). Readmission within 30 days was seen in 2 patients and readmission from 30 days- 6 months was seen in 1 patient and they underwent repeat DBE again. Indications for DBE was biliary strictures (n = 2), GI bleed (n = 2). All the patients were classified as either ASA class 3 (n = 8) or ASA class 4 (n = 1) and underwent general anesthesia. DBE was performed predominantly for indications of pancreatico-biliary interventions requiring ERCP (n = 7) or obscure GI bleeding (n = 2). Positive diagnostic yield was 88 % with major abnormal findings includes strictures with or without CBD dilation (n = 4), anastomotic ulcers (n = 3). Therapeutic yield was noted in 55 % cases and the common therapies utilized were for biliary interventions modalities (n = 5), hemoclipping, epinephrine injections (n = 1) and no intervention performed in 4 patients. No intra-procedural adverse events were noted. Conclusion: DBE in patients with Orthotopic liver transplant with hepaticojejunostomy has a high diagnostic and therapeutic yield. DBE is a useful modality for GI intervention, especially in the patients who underwent such procedures.

S3464 Rare GI Malignancy: Case of Ampullary Carcinoma

Introduction: Ampullary Pancreatic Cancer is a rare malignant tumor that only counts for 0.2% of GI tract carcinomas. It often presents with non-specific symptoms requiring high clinical suspicion. Here we describe a case of ampullary carcinoma presenting as a 3 week history of abdominal pain. Case Description/Methods: This is a 64-year-old male with a medical history of HTN and Dyslipidemia, who presented with 3-week history of dull aching intermittent epigastric abdominal pain. Exam was significant for scleral icterus and positive Murphy’s sign. Labs were significant for elevated liver enzymes, alkaline phosphatase and total bilirubin. Abdominal US showed dilated CBD measuring 11 mm and biliary sludge in the gall bladder. MRCP confirmed CBD dilatation; however, it was negative for choledocholithiasis. Subsequently, the patient underwent EUS and ERCP that showed an ampullary mass (Figure 1). Pathology findings were consistent with tubulovillous adenoma with focal adenocarcinoma. The patient underwent an exploratory laporatomy and pancreaticoduodenectomy. Biopsy revealed final pathology consistent with invasive adenocarcinoma involving the ampulla and periampullary duodenum extending to the pancreas of > 0.5 cm (mixed intestinal and pancreatobiliary type) with uninvolved margins. The postoperative course was uneventful, and he was discharged with the intention to administer adjuvant chemotherapy in an outpatient setting. Discussion: Ampullary cancer accounts for about 6% of peri-ampullary malignancies. It usually presents earlier than other peri-ampullary malignancies due to its anatomic location that may cause early biliary obstruction with jaundice. Other clinical signs are abdominal pain, weight loss and lethargy, however not specific. Laboratory and radiological workup might reveal elevation in liver enzymes and biliary dilatation, which often prompt the need for endoscopic ultrasound evaluation. In our case, the pathology report revealed stage 2 ampullary adenocarcinoma with mixed intestinal and pancreatobiliary features without metastasis or lymph node involvement. Pancreaticoduodenectomy is the first-line therapy for such patients. Prognosis and utility of adjuvant chemotherapy depend on tumor subtype with intestinal variant appear to have better outcomes. Additional research is needed to evaluate the best regimen of adjuvant chemotherapy and its significance in affecting survival for such patients following surgery.Figure 1.: A and B: two views of a mass surrounding major papilla (arrow).

Endoscopic Ultrasound versus Conventional Ultrasonography as A Diagnostic Tool for Patients with Obstructive Jaundice

Abstract Background Patient presented with jaundice, initial evaluation should be ultrasonography for evaluation of liver parenchymal changes, cirrhosis and assessment of hepatic vascularity and evaluation of intrahepatic, extrahepatic biliary system. Aim of the Work to compare between the Conventional US and Endoscopic Ultrasound in diagnosis of obstructive jaundice and other diagnostic modality including CT/MRI, ERCP for diagnosis and evaluation of the cause of OJ. Patients and Methods This study was conducted on 60 patients with obstructed jaundice as evident by ultrasonography in the form of dilated CBD with IHBRDs, with visualization of Gall bladder content and pancreas if can be well visualized, all patients had clinically apparent jaundice with disturbance of liver biochemical profile, all patient underwent EUS and compare finding with US including CBD diameter and IHBRDs degree. Results EUS provide better visualization of CBD and IHBRDs with diagnosis of pathological lesion including stones, malignancy. EUS also has better visualization of pancreatic pathology including inflammation and malignancy and extent of the tumor including local extent, lymphatic spread with vascular invasion. Conclusion EUS is better than US and other modality CT&amp;MRI and ERCP in diagnosis of distal CBD stricture including malignant obstruction especially in cases of early malignancy and small tumors, and calculary distal obstruction. CT is insensitive in diagnosis of periampullary cancer, EUS provide early diagnosis of Pancreaticobiliary malignancy and give better advandage for early resectability .

S2830 The Presentation of Hepatic Amyloidosis

Introduction: Amyloidosis is a disorder characterized by the abnormal deposition of proteins into bodily tissue. This causes changes to both organ structure and function. Amyloidosis has a wide variety of presentations which makes it a difficult diagnostic encounter. Case Description/Methods: An 81 year old male with history of choledocholithiasis, partial gastrectomy and gastroparesis presents with several months of intermittent nausea with new abnormal liver chemistries. On his initially presentation he reported fatigue, shortness of air, nausea with dry heaving and an unintentional 13lb weight loss. At this time MRCP showed dilatation of the common hepatic duct at 12mm, with hepatic changes concerning for parenchymal disease. He returned one month later with worsening elevations in alkaline phosphatase, bilirubin and creatinine. EGD showed mild chronic gastritis otherwise pathology was unrevealing. He then underwent EUS with ERCP which re-demonstrated dilated CBD, the biliary tree was swept and otherwise unremarkable. Random colon biopsies were without pathologic abnormalities. Due to continuation of symptoms with a fairly unrevealing workup he underwent liver biopsy. His liver biopsy showed diffuse replacement of the hepatic parenchyma with sheets of amorphous, eosinophilic material. Trichrome stain highlighted a predominantly sinusoidal pattern. A Congo red stain demonstrates apple-green birefringence, consistent with amyloid. Discussion: Amyloidosis consist of variable etiologies and manifestations. This case is important as it shows that hepatic amyloidosis typically presents with very non-specific symptoms and when an extensive workup has been unremarkable, amyloid should be considered. When a patient is diagnosed with amyloidosis, clinicians should be suspicious of possible predisposed factors. Amyloid is most commonly a result of an underlying process such as hematologic malignancy, chronic infection or autoimmune disease. Tissue is required for diagnosis. After diagnosis, further workup should include investigating possible underlying conditions and ruling out other organ involvement, particularly cardiac or renal involvement. Prognosis depends on subtype as well as any predisposing processes. Those with GI involvement typically have demonstrated worse outcomes. Treatment ideally includes identifying underlying processes and treating appropriately. However, others may be considered for chemotherapy or stem-cell transplant.