Dilated Common Bile Duct Research Articles

Ectopic Opening of Common Bile Duct to Duodenal Bulb: A Single Tertiary Center Experience.

The ectopic opening of the common bile duct(CBD) into the duodenal bulb is a rare biliary anomaly. The study aimed to reveal the experience with clinical and endoscopic outcomes in these patients. This study was conducted on 57 consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for ectopic opening of the CBD into the duodenal bulb at our institution between 2010 and 2020. The median age was 59 years (49 males). A total of 146 ERCP procedures were performed (once in 26 patients and 2 or more times in 31 patients). Ten patients had a history of unsuccessful ERCP in an external center. The median follow-up time was 14.6 months. All patients had a slit-like opening of the CBD into the duodenal bulb, apical stenosis, and hook-shaped distal CBD. ERCP findings were CBD stone or dilatation in 55 patients and post-cholecystectomy biliary leakage in 2 patients. Balloon dilatation was performed for apical stenosis in 7 patients and distal CBD stenosis in 26 patients. During the first ERCP session, biliary stent/nasobiliary drainage was placed in 37 patients, and CBD stones were extracted in 19 patients without stenting. Biliodigestive anastomosis was applied to 13 patients, 5 of whom had recurrent cholangitis, 7 required recurrent ERCP, and one was due to the technical difficulty of ERCP. Ectopic biliary opening should be remembered if the papilla cannot be seen in its usual place in a patient with apical stenosis. ERCP should be performed in experienced hands, and surgery should be considered in the need for recurrent ERCP.

Endoscopic ultrasound avoids diagnostic ERCP among the ASGE high-risk group – Experience in an Asian population

A prediction system for common bile duct (CBD) stones was originally published by the American Society for Gastrointestinal Endoscopy (ASGE) in 2010 and was last revised in 2019. We wanted to investigate its application in an Asian population, who have different etiologies of bile duct stone formation and accessibility to medical service compared to the West. This is a single center retrospective study. Patients who received endoscopic ultrasound (EUS) for suspected CBD stones were collected from our endoscopic record system over a 10-year period. The accuracy of the revised ASGE criteria was estimated according to the results of EUS. A minimum follow-up of 6 months was required to detect false negative results. 142 patients were enrolled, 87 (61%) patients had CBD stones. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the revised ASGE criteria for high-risk patients were 69%, 38%, 64%, 44%, and 57%. 36% of the ASGE-defined high-risk patients negative for CBD stones on EUS. The two significant predictors for CBD stone were CBD dilatation (adjusted OR 3.06, 95% C.I. 1.31-7.17, p=0.010) and ascending cholangitis (adjusted OR 2.28, 95% C.I. 1.01-5.15, p=0.047). ASGE recommends that patients defined as high-risk for choledocholithiasis be considered for direct ERCP without prior need for confirmation imaging. However, our findings indicate a high rate (36%) of patients in that group negative for CBD stones on EUS. Hence, EUS is still be suggested first in selective high-risk patients so that diagnostic ERCP can be avoided in our Asian society.

Agenesis of gallbladder-series of four cases - why it is difficult to diagnose preoperatively?

Agenesis of gallbladder (AGB) is a rare clinical entity first reported by Bergman in 1702. The incidence is about in 10–65 cases/1,00,000 population. It is seen in 1/6th cases of biliary atresia. It is of unknown etiology and is believed to be due to abnormal embryonic development. Nearly 70% cases are sporadic. AGB may be associated with other congenital abnormalities including the biliary system. The majority (nearly 50%) of the patients are symptomatic with misinterpreted signs and symptoms of cholecystitis and lands up to unnecessary surgery. Our series of four cases have male: female ratio of 3:1. Two of the cases underwent laparoscopic surgery. Among the other two, one had biliary pancreatitis due to primary calculous in the common bile duct (CBD) with upstream dilation. Other cases had chronic pancreatitis with dilated pancreatic duct and a proximal calculous close to ampulla causing proximal dilation of CBD. Two operated cases were postoperatively diagnosed by magnetic resonance cholangiopancreatography (MRCP) and the non-operated patients were also diagnosed by MRCP. Symptomatic AGB is often wrongly interpreted as cholecystitis with cystic duct obstruction or as sclero-atrophic gallbladder, therefore leading to pointless surgical interventions. In case of false-positive ultrasonography (USG) of AGB, it has been suggested that either a loop of gas-containing bowel located in the gallbladder fossa or periportal tissue and subhepatic peritoneal folds impersonate a contracted gallbladder containing gallstones. When USG reveals such reports or in cases of non-visualization in other imaging modalities, the need of additional preoperative imaging investigation must be in the surgeon’s mind such as MRCP to avoid surgery which is not at all required.

1102 A Rare Case of Parenchymal Liver Injury Presenting Initially as an Obstructive Jaundice

Abstract Parenchymal liver damage is secondary to a sudden insult on hepatocytes, most commonly due to hepatitis or secondary to drug injury. A 43-year-old gentleman with a pre-existing diagnosis of fatty liver disease, presented with obstructive jaundice. He had a bilirubin of 159 and ultrasound imaging showed gallstones in his gallbladder with a dilated common bile duct (CBD) of 6.7mm. An MRCP showed a dilated CBD with an intraluminal filling defect. He was discharged home when clinically well and referred for an outpatient ERCP. This did not happen for three weeks and at this point, no cause of obstruction was identified, but a plastic biliary stent was inserted. Despite this, his liver function worsened, and he was readmitted with a bilirubin of 421. Following discussion within a multidisciplinary team he underwent a further CT scan and ERCP with stent replacement, these showed no evidence of obstruction. All acute hepatic and virology screens were negative. His bilirubin continued to uptrend hitting 644 and he became coagulopathic with an elevated INR of 2.7. The patient admitted to taking weight loss supplements including a “fat burner” powder regularly for the last two months, in keeping with the duration of his worsening liver dysfunction. He underwent a liver biopsy; the results of which are pending and is currently being treated supportively. This case presented an interesting diagnostic challenge and there remains ongoing uncertainty. The current working diagnosis is that of an obstructive jaundice which has exacerbated an underlying parenchymal liver injury secondary to supplement use.

Recurrent Choledocholithiasis: Unveiling the Diagnostic Challenges of Profound Transaminitis Post Cholecystectomy.

BACKGROUND Profound transaminitis (>1000 international units per liter [IU/L]) is typically associated with ischemic and viral or toxic hepatitis. Pancreaticobiliary causes are less likely to be included in the workup, especially in patients who have undergone cholecystectomy. We present a case of recurrent choledocholithiasis in a 52-year-old woman 7 years after cholecystectomy, presenting with severe transaminitis, illustrating the diagnostic challenges of this presentation. CASE REPORT A 52-year-old woman presented to the Emergency Department (ED) with acute upper abdominal pain. Computed tomography (CT) of the abdomen without contrast showed no abnormalities and mild common bile duct (CBD) dilation was noted on ultrasound (US) abdomen. Laboratory studies were significant for elevated transaminases greater than 1000 units/L and alkaline phosphatase (ALP) greater than 200 units/L. She was diagnosed with acute hepatitis of unknown etiology without undergoing further investigation of the biliary tract and was discharged after improvement with supportive therapy. She returned 4 months later with similar symptoms and laboratory findings, but with more CBD dilation and intrahepatic biliary dilation on CT and US. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and multiple stones and sludge were removed from the CBD. CONCLUSIONS This report has shown that pancreaticobiliary causes should be included in the workup of severe transaminitis, even in patients with a remote history of cholecystectomy. Failure to do so may subject patients to extensive, unnecessary workup and delay correct management.

235 A case of Painless Palpable Gall bladder - a rare Exception of the Courvoisier's Law

Abstract Introduction The Courvoisier's law states that a painless palpable enlarged gallbladder with jaundice is unlikely to be caused by gallstones. There are however various exceptions to the law. We report a rare case of such an exception to make us aware of the clinical condition. Case Description 72-year-old male, otherwise fit and healthy, presented to the Emergency department with epigastric discomfort, along with dark urine and pale-coloured stool. He was clinically examined to have jaundice, and a painless globular palpable gall bladder, with blood results confirming obstructive picture i.e. raised bilirubin (70 μmol/L), ALT (103 U/L) and Alkaline Phosphatase (590 IU/L). Ultrasound abdomen showed acute cholecystitis. CT chest-abdomen-pelvis showed cholelithiasis and choledocolithiasis with dilated common bile duct (CBD), as well as asymmetric gallbladder wall thickening. The MRCP showed concentric and uniform thickening of the entire gallbladder wall, with minimal pericholecystic fluid reflecting acute inflammation. Multiple calculi were noted to be present within the CBD and gall bladder, resulting in dilation of CBD (15.8mm). The patient had ERCP with sphincterotomy and retrieval of multiple stones by balloon trawl. He was discharged the following day and is planned to undergo laparoscopic cholecystectomy as an elective procedure. His liver function test markedly improved at discharge bilirubin of 18 μmol/L and ALP of 364 IU/L. Conclusion This is an unusual case of painless jaundice with palpable gall bladder due to stones impacted in the CBD and not due to periampullary carcinoma, which is an exception to the Courvoisier's Law.

270 The Liberal Use of Magnetic Resonance Cholangiopancreatography (MRCP) can be switched over to its Selective use to detect choledocholithiasis

Abstract Background Gallstone disease is known in 10-15% of adults in Western populations. Cholangiopancreatography is the investigation of choice for choledocholithiasis; however, its use is varied, and guidelines are not well-defined. The NICE guidelines recommend MRCP be done when common bile duct dilatation ≥ 8mm or liver function tests) are abnormal but do not quantify this further. The liberal use of MRCP is gaining popularity as a roadmap prior to cholecystectomy, aiming to assess primarily for the presence of migrated gallstones within the cystic duct or common bile duct, as well as providing information regarding the anatomical features of the extrahepatic biliary tree on an individualized basis. Due to these reasons, MRCP is at times done unnecessarily which creates an economic burden and restricts access to patients in real need of imaging slots. Method It is a hospital-based retrospective observational study. The time frame was July 2021 to July 2022. The sample size was 230 patients. Result Our Study showed that isolated elevated Alanine Aminotransferase levels should not be a reason to evaluate patients for Choledocholithiasis. It concluded that elevated serum bilirubin levels, Alkaline Phosphatase, and Gamma Glutamyl Transferase are the strongest predictors of CBD stones in patients with gallstone disease and hence can be used to triage patients for undergoing MRCP. Conclusions To conclude elevated serum bilirubin levels, ALP and GGT are the strongest predictors of CBD stones in patients with gallstone disease and hence can be used to triage patients for undergoing MRCP. Isolated elevated ALT should not be a reason to evaluate patients for CBD stones.

226 The Liberal Use of Magnetic Resonance Cholangiopancreatography (MRCP) can be switched over to its Selective use to detect choledocholithiasis

Abstract Gallstone disease is known in 10-15% of adults in Western populations. Cholangiopancreatography (MRCP) is the investigation of choice for choledocholithiasis; however, its use is varied, and guidelines are not well defined. The National Institute for Health and Care (NICE) guidelines recommends MRCP to be done when common bile duct (CBD) dilatation ≥ 8mm or liver function tests (LFTs) are abnormal but do not quantify this further. The liberal use of magnetic resonance cholangiopancreatography (MRCP) is gaining popularity as a roadmap prior to cholecystectomy, aiming to assess primarily for the presence of migrated gallstones within the cystic duct or common bile duct, as well as providing information regarding the anatomical features of the extrahepatic biliary tree on an individualised basis .Due to these reasons MRCP’s at times are done unnecessarily which creates economic burden and restricts access to patients in real need of imaging slots The aim of this retrospective study was to identify whether magnetic resonance cholangiopancreatography (MRCP) can be used selectively in patients with deranged liver enzymes with gallstone disease to detect choledocholithiasis, based on liver function tests (LFTs) and ultrasonography appearance.

The Association Between Common Bile Duct Diameter and the Severity of Coronary Artery Atherosclerosis, Based on Calcium Score

Objective: The aim was to assess the relationship between the coronary calcium score and the common bile duct (CBD) diameter, to determine whether the increase in CBD diameter in patients without hepatobiliary disease could represent cardiovascular disease, or the extent of atherosclerosis in coronary arteries. Materials and Methods: The study cohort consisted of 103 patients referred for computed tomographic angiography (CTA) for coronary artery assessment. None of the patients had a gallbladder, biliary, or pancreatic disease or surgery history. The Agatston score determined the rates of arterial calcification. The diameter of the CBD was measured for a sonogram. Results: There was a statistically significant relatively strong correlation between calcium score and CBD diameter ( r = 0.44, P = .001), independent of baseline variables, such as demographics and cardiovascular risk profiles. In the multivariable regression model, advanced age (beta = 0.825, P = .005), history of hypertension (beta = 0.591, P = .034), and history of coronary stenting (beta = 1.339, P = .001) were shown to be the main determinants of CBD dilatation. Conclusion: A statistically significant correlation existed between the CBD diameter and calcium score, within the coronary arteries and this could represent a shared pathophysiology between CBD dilatation and the severity of coronary atherosclerosis.

Utility of the "BATS" Score in Predicting Choledocholithiasis in Patients With Gall Bladder Stones.

Background and aim The role of expensive, risky, and unnecessaryendoscopic interventions can be avoided by the use of non-invasive tests to predict common bile duct (CBD) stones. Therefore, our aim was to identify non-invasive predictors of choledocholithiasis (CL) in patients and further to predict a model and assess its diagnostic accuracy in predicting CL. Methods This cross-sectional study was carried out from June 1, 2020, to December 31, 2021. Patients having gall bladder stones on percutaneous transabdominal sonography and fulfilling intermediate probability criteria of CL were enrolled. These patients then underwent radial endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatography (ERCP) for detecting CBD stones. Univariate logistic regression analysis, followed by multivariate logistic regression analysis, was performed to ascertain the independent predictors of CBD stone in patients with intermediate probability. A model was proposed, and the diagnostic accuracy was calculated at an optimal cutoff. The model was then internally validated in the patients with intermediate probability and was also compared with the pre-existing score. Results Out of 131 patients included in the study, CBD stone was noted in 85 (66%) and 88 (67.2%) patients on EUS and ERCP, respectively. On multivariate analysis, high serum bilirubin (>2 mg/dL) and alkaline phosphatase (200 IU) and dilated CBD (>6 mm) on transabdominal sonography at baseline were significant predictors of CBD stone in these patients. Using these variables, a scoring system (BATS score) was developed, which had an area under the receiver operating curve (AUROC) of 0.98 in predicting the presence of CBD stone with a sensitivity of 93.18%, a specificity of 76.74%, and a diagnostic accuracy of 87.79%. In the validation cohort, a BATS score of ≥5 had a diagnostic accuracy of 95.91% in predicting CL. Conclusion TheBATS scoreshowed excellent sensitivity and good diagnostic accuracy in predicting the CBD stonewith excellent results on internal validation. However, external validation of our results is required to recommend this model on a larger scale.

The association between sonographic common bile duct dilatation and outcomes in emergency department patients with cholangitis.

The presentation of the patient with acute cholangitis (AC) ranges from mild illness to life-threatening shock. Therefore, prompt diagnosis and treatment are critical. Abdominal ultrasound (US) is the imaging of choice to locate bile duct dilatation. Other modalities include abdominal computed tomography (CT) or endoscopic retrograde cholangiopancreatography (ERCP). To determine whether sonographic common bile duct dilatation in emergency department (ED) patients with AC predicts outcomes including sepsis, hospital length of stay (LOS), admission to the intensive care unit (ICU), time to ERCP, and mortality. Electronic medical records of all patients hospitalized in a tertiary care medical center between July 2012-February 2021 with a discharge diagnosis of cholangitis were assessed. Patients were dichotomously classified as CBD dilated or CBD non-dilated based on ultrasound. Dilation was defined as CBD larger than 6 mm in patients younger than 60 or larger than 6 mm + 1 mm per decade in patients over 60. The study included 271 patients- 172 with CBD dilation versus 99 without. Mean LOS was 9.92 days for those with a dilated CBD versus 13.4 days without. The mean time to ERCP was 4.26 days for those with a dilated CBD versus 6.56 days without. Sepsis, mortality, and ICU admission were scarce and there was no statistically significant difference between the cohorts. Patients with a dilated CBD per the abdominal US performed during the patient's ED stay, underwent ERCP earlier, and were hospitalized fewer days than patients without CBD dilation.

Comparison of MRCP and ERCP in the evaluation of common bile duct and pancreatic duct pathologies.

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging modality that has high diagnostic accuracy for a wide range of bile duct and pancreatic duct pathologies. Endoscopic retrograde cholangiopancreatography (ERCP) is still the gold standard for the exploration of the biliopancreatic region. The aim of the study was to compare the diagnostic accuracy of MRCP with that of ERCP in the diagnosis of bile duct and pancreatic duct pathologies. A total of 60 patients with common bile duct (CBD) and pancreatic duct pathologies detected on MRCP were subsequently evaluated by ERCP in this observational study. A comparison of MRCP findings with ERCP was made. MRCP had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 88.1%, 94.4%, 97.3%, 72.7%, and 90%, respectively, in diagnosing choledocholithiasis in comparison to ERCP. For CBD dilation, the sensitivity was 90.91%, specificity was 93.75% and the PPV, NPV, and accuracy were 97.56%, 78.95%, and 91.67%, respectively, for MRCP. In CBD stricture, MRCP showed a sensitivity, specificity, PPV, NPV, and accuracy of 83.33%, 97.92%, 90.91%, 95.92%, and 95%, respectively. In pancreatic duct dilatation, the sensitivity, specificity, PPV, NPV, and accuracy were all 100%. Pancreatic duct stricture showed a sensitivity, specificity, PPV, NPV, and accuracy of 80%, 98%, 88.89%, 96.08%, and 95%, respectively. For the diagnosis of periampullary carcinoma, the sensitivity, specificity, PPV, NPV, and accuracy rate of MRCP were 80%, 98%, 88.89%, 96.08%, and 95%, respectively. No significant difference was found between MRCP and ERCP in diagnosing those six pathologies.

THE SIGNIFICANCE OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) IN THE DETECTION OF SUSPECTED CHOLEDOCHOLITHIASIS.

Background: Magnetic resonance cholangiopancreatography (MRCP) is a radiation-free test that can be performed quickly and does not expose patients to ionizing radiation or iodinated contrast material. The present study is intended to evaluate the role of MRCP in the detection of Common Bile Duct (CBD) stones in patients with suspected choledocholithiasis. Thi Materials and Methods: s prospective study included 64 patients with suspected choledocholithiasis which was based on clinical evaluation and biochemical or ultrasonographic examination. MRCP was done in all patients. All presenting patients underwent open surgery after proper investigation. CBD exploration was performed in all patients, either due to the presence of palpable stones or due to the presence of dilated CBD (≥8 mm). Demonstration of CBD stones intra-operatively was considered the gold standard' for their presence, dened as stones visualized and extracted or attempted for extraction during surgical CBD exploration. Results: Intraoperatively, 45 (70.3%) out of 64 patients had cholelithiasis. 55 (85.93%) out of 64 patients had dilated CBDs. In 43 (67.18%) out of 64 patients, choledocholithiasis was detected intraoperatively. The sensitivity, specicity, and positive and negative predictive value of ultrasonography in detecting CBD stones in the present study were found to be 65.11%, 61.9%, 77.77% and 46.43% respectively. The sensitivity, specicity, positive predictive value and negative predictive value of MRCP in the diagnosis of CBD stones in the present study were 95.35%, 90.47%, 95.35% and 90.48% respectively. MRCP is a non–invasive and uncomplicated investigation w Conclusion: ith high sensitivity, specicity, and positive and negative predictive values for the detection of CBD stones. Hence MRCP is advised in all cases with a suspicion of CBD stones, where facilities and expertise are available.

Predictors of technical success of percutaneous transhepatic common bile duct stone removal: is it only a matter of stone size?

The common practice is to remove symptomatic common bile duct (CBD) stones in patients. This study aimed to investigate the factors affecting the percutaneous transhepatic removal of CBD stones. We retrospectively analyzed the data of 100 patients (66 men and 34 women; age: 25-105years, mean 79.1years) with symptomatic CBD stones who underwent percutaneous transhepatic stone removal (PTSR) from January 2010 through October 2019. After balloon dilation of the ampulla of Vater or bilioenteric anastomosis, the stones were pushed out of the CBD into the small bowel with a balloon catheter. If failed, basket lithotripsy was performed. Technical success was defined as complete clearance of the bile ducts on a cholangiogram. The technical success rate was 83%, and achieved 90.2% in patients with altered gastroduodenal/pancreatobiliary anatomy. Multivariable analysis revealed that CBD diameter (odds ratio [OR]: 506.460, p = 0.015), failed ERCP (OR: 16.509, p = 0.004), Tokyo guidelines TG18/TG13 severity (grade III; OR: 60.467, p = 0.006), and left-sided transhepatic approach (OR: 21.621, p = 0.012) were risk factors for technical failure. The appropriate cutoff CBD size was 15.5mm (area under the curve: 0.91). CBD stone size, radiopacity of stones, and CBD angle between retroduodenal and pancreatic portion did not influence technical success. PTSR is effective for CBD stone removal in older adults and individuals with altered gastrointestinal tract anatomy. The aforementioned risk factors for technical failure should be considered in preoperative evaluation before PTSR to improve the success rate. • PTSR is effective in symptomatic CBD stone management among older adults and individuals with altered anatomy. Investigating clinical /anatomic factors can guide radiologists toward a more comprehensive preoperative evaluation to maximize the success rate. • Our data indicate that dilated CBD (diameter ≥ 15.5mm) and left-sided PTBDs reduce the technical success rate by 506-fold and 22-fold, respectively. • Clinical factors such as previous failed ERCP for stone removal and higher severity of acute cholangitis lessen the technical success rate.

Role of endoscopic ultrasound in the characterization of solid pseudopapillary neoplasm of the pancreas.

Solid pseudopapillary neoplasm (SPN) is an uncommon pathology of the pancreas with unpredictable malignant potential. Endoscopic ultrasound (EUS) assessment plays a vital role in lesion characterization and confirmation of the tissue diagnosis. However, there is a paucity of data regarding the imaging assessment of these lesions. To determine the characteristic EUS features of SPN and define its role in preoperative assessment. This was an international, multicenter, retrospective, observational study of prospective cohorts from 7 large hepatopancreaticobiliary centers. All cases with postoperative histology of SPN were included in the study. Data collected included clinical, biochemical, histological and EUS characteristics. One hundred and six patients with the diagnosis of SPN were included. The mean age was 26 years (range 9 to 70 years), with female predominance (89.6%). The most frequent clinical presentation was abdominal pain (80/106; 75.5%). The mean diameter of the lesion was 53.7 mm (range 15 to 130 mm), with the slight predominant location in the head of the pancreas (44/106; 41.5%). The majority of lesions presented with solid imaging features (59/106; 55.7%) although 33.0% (35/106) had mixed solid/cystic characteristics and 11.3% (12/106) had cystic morphology. Calcification was observed in only 4 (3.8%) cases. Main pancreatic duct dilation was uncommon, evident in only 2 cases (1.9%), whilst common bile duct dilation was observed in 5 (11.3%) cases. One patient demonstrated a double duct sign at presentation. Elastography and Doppler evaluation demonstrated inconsistent appearances with no emergence of a predictable pattern. EUS guided biopsy was performed using three different types of needles: Fine needle aspiration (67/106; 63.2%), fine needle biopsy (37/106; 34.9%), and Sonar Trucut (2/106; 1.9%). The diagnosis was conclusive in 103 (97.2%) cases. Ninety-seven patients were treated surgically (91.5%) and the post-surgical SPN diagnosis was confirmed in all cases. During the 2-year follow-up period, no recurrence was observed. SPN presented primarily as a solid lesion on endosonographic assessment. The lesion tended to be located in the head or body of the pancreas. There was no consistent characteristic pattern apparent on either elastography or Doppler assessment. Similarly SPN did not frequently cause stricture of the pancreatic duct or common bile duct. Importantly, we confirmed that EUS-guided biopsy was an efficient and safe diagnostic tool. The needle type used does not appear to have a significant impact on the diagnostic yield. Overall SPN remains a challenging diagnosis based on EUS imaging with no pathognomonic features. EUS guided biopsy remains the gold standard in establishing the diagnosis.

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma.

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma.

TYPE IV-A CHOLEDOCHAL CYST IN NEWBORN

A congenital cystic dilatation of the bile duct is called a choledochal cyst; it may involve the extrahepatic, intrahepatic, or both biliary radicles. It is an uncommon illness that affects people more frequently in developing nations. We describe a highly uncommon case of a male newborn who has Type IV-A choledochal cyst. The denitive diagnosis was made based on magnetic resonance cholangiopancreatography (MRCP) which showed left sided dilated intrahepatic biliary radicals with fusiform dilatation of common bile duct (CBD) and common hepatic duct (CHD). The decision to follow up with a subsequent surgical plan was taken because there were no complications and the bilirubin level returned to normal after conservative treatment.

Prediction of common bile duct stones in acute cholecystitis patients at time of hospital admission

Background Early diagnosis of common bile duct stone (CBDS) is crucial since its presence affects surgical therapy and acute calculous cholecystitis (ACC) has a comparable clinical picture whether or not a CBDS is present. Aim At the time of hospital admission, we sought to discover predictors of CBD stones in acute cholecystitis (AC) patients. Methods Between January 2020 and December 2022, we chose 90 patients who had typical ACC and had previously visited the emergency room at Minia University Hospital in Egypt. The 90 AC patients were split into two groups: the 63 AC patients without CBD stones and the 27 AC patients with CBD stones. The data were obtained and compared between the two groups include gender, age, history of chronic calcular cholecystitis (CCC), white blood cells (WBC), liver function tests (LFT), and common bile duct (CBD) diameter. Results By using simple logistic regression analysis for prediction of CBD stones, old age > 55 years, CBD diameter more than 6 mm and elevated liver functions including total bilirubin, direct bilirubin, serum glutamic-pyruvic transaminase (SGPT), serum glutamic-oxaloacetic transaminase (SGOT), alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) was associated with CBD stones. By using multiple logistic regression analysis, only 2 variable showing significant association with CBD stones, including old age > 55 years (P = 0.013, odds ratio 9.26, confidence interval 1.6–53.61) and direct bilirubin (P = 0.008, Odds ratio 55.67, confidence interval 2.89–1072.35). Conclusion Age, abnormal LFTs greater than twofold, and dilated CBD >6 mm in AC patients increase the likelihood of concurrent CBDS. Knowing about these results might assist physicians develop clinical suspicions for an earlier diagnosis and improved management of CBDS.

Predictive model of persistent choledocholithiasis in patients with acute biliary pancreatitis.

Choledocholithiasis causing acute biliary pancreatitis (ABP) may migrate to the duodenum or persist in the common bile duct (CBD). We developed a model for predicting persistent choledocholithiasis (PC) in patients with ABP. This retrospective cohort study included 204 patients, age ≥18 years (mean age: 73 years, 65.7% women), admitted for ABP in 2013-2018, with at least a magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and/or endoscopic retrograde cholangiopancreatography (ERCP). Epidemiological, analytical, imaging, and endoscopic variables were compared between patients with and without PC. Multivariate logistic regression analyses were performed to develop a predictive model of PC. Patients underwent MRCP (n=145, 71.1), MRCP and ERCP (n=44, 21.56%), EUS and ERCP (n=1, 0.49%), or ERCP (n=14, 6.86%). PC was detected in 49 patients (24%). PC was strongly associated with CBD dilation, detected in the emergency ultrasound (p<0.001; OR=27; 95% CI: 5.8-185.5), increased blood levels of gamma glutamyl transpeptidase, detected at 72h (p=0.008; OR=3.4; 95% CI: 1.5-8.9); and biliary sludge in the gallbladder (p=0.008; OR=0.03; 95% CI: 0.001-0.3). The predictive model showed a validated area under the curve (AUC) of 0.858 for detecting PC in patients with ABP. A nomogram was developed based on model results. The predictive model was highly effective in detecting PC in patients with ABP. Therefore, this model could be useful in clinical practice.

Diagnostic Value of Endoscopic Ultrasonography (EUS) in Unexplained Common Bile Duct Dilatation

Diagnostic Value of Endoscopic Ultrasonography (EUS) in Unexplained Common Bile Duct Dilatation