Dilated Common Bile Duct Research Articles

Man with episodic abdominal pain andjaundice.

A 51-year-old man without a past medical history presented to our emergency department with 2 months of intermittent epigastric pain radiating to the back, tan stools, fatigue, and weight loss. He denied current alcohol use. He appeared diffusely jaundiced. His abdomen was soft with mild epigastric tenderness and a negative Murphy sign. Serum analysis showed total bilirubin 13.7, aspartate transaminase 207, alanine transaminase 463, alkaline phosphatase 634, lipase > 4000, elevated carcinoembryonic antigen/carbohydrate antigen 19-9, and negative hepatitis panel. Imaging included point-of-care (POC) ultrasound (Figure 1, Video 1), computed tomography (CT; Figure 2), magnetic resonance imaging (MRI; Figure 3), and endoscopic retrograde cholangiopancreatograph (ERCP; Figure 4). Our patient had obstructive jaundice. POC ultrasound revealed a distended gallbladder with sludge without signs of acute cholecystitis. The dilated common bile duct >10 mm (normal < 6 mm) and dilated pancreatic duct >5 mm (normal < 3 mm) were consistent with the rare double duct sign. Dilatation without a clear etiology was confirmed on MRI and CT. ERCP revealed a duodenal ulcer with biopsy positive for invasive, poorly differentiated adenocarcinoma. Finally, a pancreaticoduodenectomy revealed a tumor of the pancreatic head. Etiologies of the double duct sign include neoplasms of the pancreatic head and ampulla of Vater and less commonly choledocholithiasis and chronic pancreatitis.1 Overall prevalence of associated malignancy varies from 58% to 100%.2 However, the presence of jaundice is strongly associated with malignancy whereas absence with benign conditions.3-5 Isodense culprit neoplasms are often not visualized on advanced imaging. As initial presentation of pancreatic cancer is insidious, the ominous presence of this sign should raise concerns for malignancy. The authors would like to thank Daniela Galan Alonso, MD, Department of Radiology, Jackson Memorial Hospital. Video.1 Point-of-care ultrasound of pancreas revealing double duct sign. Gallbladder (star), pancreatic duct (arrow), and common bile duct (circle). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Research for clinical, biological and endoscopic ultrasound characteristics of pancreatic tumors

Background: Pancreatic tumor disease often has clinical symptoms ambiguously which is leading to late detection and poor prognosis. Currently, there are many imaging methods to use for the early detection, and diagnosis of pancreatic tumors. Endoscopic ultrasound (EUS) with the strength of a high-frequency probe, approaching directly the pancreas which is improving the diagnosis of the tumor, especially small lesions &lt; 2 cm. This study was aimed at: (1) To describe some clinical, biological, and endoscopic ultrasound characteristics of pancreatic tumors. (2) To evaluate the relationship between clinical and biological characteristics and pancreatic tumor characteristics on endoscopic ultrasound. Subject and methods: Cross-sectional study in 41 patients diagnosed with pancreatic tumor on endoscopic ultrasound. Results: Common history was smoking, high intake of alcohol and diabetes. Almost half of the patients 48.5% had a CA 19.9 ≤ 37 U/ml. Lesions in the pancreatic head accounted for 80.5%, hypoechoic lesions 97.6%, solid tumor 80.5%. Common extra-tumoral findings were abdominal lymph nodes accounting for 51.2%, common bile duct dilatation 46.3% and pancreatic duct dilatation 39.0%. There was no relationship between levels of CA 19.9 and endoscopic ultrasound features such as vascular invasion, and lymph node metastasis (p &gt; 0.05). There was a statistically significant relationship of tumors in the head of the pancreas and jaundice, and dilation of the common bile duct (p &lt; 0.05). Conclusion: Smoking, high intake of alcohol and diabetes were the most common history. Common findings of tumor were hypoechoic, solid tumor and pancreatic head position. There is a relationship of pancreatic head tumors and jaundice as well as dilation of the common bile duct. Key words: endoscopic ultrasound, pancreatic tumor, clinical features, biochemical characteristics.

Post-Cholecystectomy Biliary Dilatation

Introduction: Despite the fact that the common bile duct (CBD) is thought to dilate following surgery, post-cholecystectomy CBD dilatation still remains a source of debate. Intravenous cholangiography made it possible to measure the common duct directly. Although most patients did not have a substantial increase in duct diameter following cholecystectomy, there was a trend toward a modest degree of duct dilatation, according to prospective studies employing sonography to assess the common duct. Objective: To determine the frequency of common bile duct dilatation after cholecystectomy for chronic cholecystitis. Study Design: Descriptive study Place and Duration of Study: General Surgery Department, Hayatabad Medical Complex, Peshawar from 1st February 2020 to 31st January 2021. Methodology: Eighty seven patients and age range is 20-60 years booked for cholecystectomy in outpatient department were included and followed up to 6 month to determine the frequency of common bile duct dilatation. Results: The mean age was 38.6±10.3 years with 25 (28.7%) males and 62 (71.2%) females. Mean body mass index of the sample was 25±2.3kg/m2. Sixty (68.9%) underwent laparoscopic cholecystectomy while 17 (19.5%) underwent open cholecystectomy. Mean baseline common bile duct diameter on ultrasound was 1.3±0.1 mm while the mean follow up common bile duct diameter was 1.8±0.2 mm (p&lt;0.001). Common bile duct dilatation was recorded in 20 (22.98%) patients. Conclusion: Common bile duct dilatation after cholecystectomy is controversial, but in asymptomatic patients, a dilation of up to 10mm should be accepted as normal. Keywords: Cholecystectomy, Cholecystitis, Common bile duct dilatation, Body mass index

The liberal use of magnetic resonance cholangiopancreatography can be switched over to its selective use to detect choledocholithiasis

Background: Gallstone disease is known in 10-15% of adults in Western populations. Magnetic resonance 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 ≥8 mm or liver function tests (LFTs) 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 individualised basis. Due to these reasons MRCP at times is done unnecessarily which creates economic burden and restricts access to patients in real need of imaging slots. Methods: It is hospital based retrospective observational study. Time frame was July 2021 to July 2022 and sample size was 230 patients. Results: Our study showed that isolated elevated alanine aminotransferase (ALT) level should not be reason to evaluate patients for choledocholithiasis. It concluded that elevated serum bilirubin levels, alkaline phosphatase (ALP) and gamma glutamyl transferase (GGT) 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.

An uncommon cause of pancreatitis with obstructive jaundice

A 56-year-old man with a history of diabetes mellitus poorly controlled recently (HbA1c: 7.5%, <6%) presented with a 3-month history of postprandial epigastric pain, 10-kg weight loss, steatorrhea, tea-colored urine, and clay-colored stool. Physical examination revealed yellowish skin and icteric sclera but no peripheral stigmata of cirrhosis. Laboratory investigation was significant for elevated aspartate aminotransferase (289 IU/L, 8-31 IU/L), alanine aminotransferase (613 IU/L, 0-41 IU/L), alkaline phosphatase (595 U/L, 34-104 U/L), γ-glutamyl transferase (758 U/L, 0-26 U/L), total and direct bilirubin (8.0/6.1 mg/dL, 0.3-1/0.03-0.18 mg/dL), and carbohydrate antigen 19-9 (289 U/mL, <37 U/mL). Contrast-enhanced computed tomography revealed diffuse enlargement of the pancreas (arrow) and dilatation of the common bile duct (CBD) without identifiable stone or a mass lesion (arrowhead; Figure 1A). Endoscopic ultrasound (EUS) demonstrated hyperechoic foci and strands in the enlarged pancreas (arrow) and layer-by-layer whole wall thickening with a hyper-hypo-hyperechoic series (sandwich pattern) of CBD (arrowhead) as well as gallbladder (star; Figure 1B). Magnetic resonance cholangiopancreatography (MRCP) showed dilated CBD with distal tapering near the pancreatic head (arrow; Figure 1C). The diagnosis of autoimmune pancreatitis was confirmed by serologic immunoglobulin G4 (IgG 4) elevation (IgG 4: 2880 mg/dL, 3-201 mg/dL) and favored type I according to nonductal Level 1/Level 2 criteria of international consensus diagnostic criteria.1 The patient recovered from jaundice and gained weight after treatment of prednisone 40 mg/d for 4 weeks, then taper by 5 mg/wk. The 8-week follow-up EUS demonstrated normalization of pancreatic size (arrow) and CBD morphology (arrowhead; Figure 2).2 Autoimmune pancreatitis mimicking pancreatic cancer is a rare cause of obstructive jaundice with an estimated incidence of 1 per 100 000.3 In summary, we demonstrated a case of autoimmune pancreatitis diagnosed by complement image study and elevating serum IgG 4, which achieved successful medical treatment of obstructive jaundice without further invasive procedures.1 The authors declare no conflict of interest. This report was approved by the Research Ethical Committee of Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (No. CR111-08).

Esophageal Fully-Covered Metal Stent as a Rescue Therapy for a Strasberg Type A Biliary Leak in a Huge Common Bile Duct Dilation.

Treatment of biliary leaks is challenging and complex. Even if endoscopic sphincterotomy with biliary stenting is usually resolutive in restoring the original bile flow, common bile duct (CBD) diameter is crucial in defining the size and features of the stent. Additional factors, such as uncommon anatomical reconstructions due to a previous abdominal surgery, could make the endoscopic approach more difficult, therefore increasing the risk of failure. Many articles deal with uncommon technique adopted to allow an optimal healing of biliary leaks but, thus far, only two reports of biliary stent using an esophageal through-the-scope (TTS), partially-covered, self-expandable metal stent (SEMS) exist in the current literature. This article describes the deployment of an esophageal SEMS into the CBD for a refractory type A Strasberg fistula in a Billroth-II reconstruction. To our knowledge, this is the first report concerning the use of an esophageal stent for CBD drainage in a Billroth-II reconstruction.

A model for predicting degree of malignancy in patients with intraductal papillary mucinous neoplasm.

There is no predictive model available to address early stage malignant intraductal papillary mucinous neoplasm (IPMN) including high grade dysplasia (HGD) and pT1a (invasive component≤0.5 cm). The aim of this study was to establish an objective and sufficient model to predict the degree of malignancy in patients with IPMN, which can be easily applied in daily practice and adopted for any type of lesion. A retrospective cohort study of 309 patients who underwent surgical resection for IPMN was performed. Members of the cohort were randomly allocated to the training or testing set. A detection tree model and random forest model were used for a 3-class classification to distinguish low grade dysplasia (LGD), HGD/pT1a IPMN, and invasive intraductal papillary mucinous cancer (I-IPMC) beyond pT1a. Of the 309 patients, 54 (17.4%) had early stage malignancy (19 HGD, 35 pT1a), 49 (15.9%) had I-IPMC beyond pT1a, and 206 (66.7%) had LGD IPMN. We proposed a 3-class classification model using a random forest algorithm, and the model had an accuracy of 99.5% with the training set, and displayed an accuracy of 96.0% with the testing set. We used SHAP for interpretation of the model and showed the top five factors (mural nodule size, main pancreatic duct diameter, CA19-9 levels, lesion edge and common bile duct dilation) were most likely to influence the 3-class classification results in terms of interpretation of the random forest model. This predictive model will help assess an individual's risk for different stages of IPMN malignancy and may help identify patients with IPMN who require surgery.

Spontaneous Rupture of Choledochal Cyst: A Rare Presentation

AbstractCholedochal cyst (CDC) is a rare surgical cause of cholestatic jaundice in infants. Spontaneous rupture is an unusual presentation of a previously undiagnosed CDC and is also a rare cause of biliary peritonitis in children. Here, we report a case of a 1-year-old boy who was evaluated for progressive abdominal distension. Ultrasonogram showed gross ascites with echogenic particles, dilated common bile duct (CBD), common hepatic duct (CHD), and upstream intra hepatic biliary radicle dilatation (IHBRD). CECT sections of the abdomen showed gross ascites and IHBRD with disproportionate dilatation of CHD and CBD. At laparotomy, a type 1 CDC with rupture of the anterior wall was found. The cyst was excised followed by hepaticojejunostomy. In a sick child with abdominal pain, cholestatic jaundice and biliary ascites, a high index of suspicion during imaging will help in the correct diagnosis and surgery for a potentially fatal ruptured CDC.

Type IVA Choledochal Cyst in Adult: A Case Report

Choledochal cyst is a congenital disease of the biliary tract with extrahepatic and/or intrahepatic biliary tree dilatation. There is a female majority (4:1). Controlling biliary sepsis and curing pancreatitis are prerequisites of surgery. Here, a 35-year-old female patient, came with complaints of epigastric and right upper abdominal pain for three days. On examination per abdomen was soft, non distended, right hypochondriac tenderness was present, no guarding, bowel sounds were audible. Magnetic Resonance Cholangiopancreatography (MRCP) was done which showed fusiform dilatation of Common Bile Duct (CBD), Common Hepatic Duct (CHD), right and left hepatic duct, along with mild dilatation of central intrahepatic biliary radicals (4.8-5 mm)- suggestive of choledochal cyst type IVA. Hepatico-duodenostomy was done. The entire extrahepatic biliary tree should be removed when the choledochal cyst is diagnosed whether or not symptoms are present. Despite being congenital, the condition is typically discovered in adulthood as well. The treatment of choledochal cysts has evolved. The current standard of care is cyst excision and hepaticojejunostomy

Intraperitoneal rupture of the hydatid cyst disease: Single-center experience and literature review.

The primary aim of this study was to present our experience on intraperitoneal rupture of the hydatid cyst in guidance of literature data. Demographical, clinical, radiological and postoperative follow-up data of 29 patients who underwent surgical treatment in our institution with an indication of intraperitoneal rupture of the hydatid cyst from January 2003 to July 2020 were analysed retropectively. Among the 29 patients with an age range of from 16 to 79 years ( median= 39, IQR=25.5), 16 were male (55.2%) and 13 were female (44.8%). Intraperitoneal rupture of the hydatid cyst was spontaneous in 21 (72.4%), traumatic in 7 (24.13%) (2 of them were iatrogenic) and was due to shotgun in one patient. Vast majority of the patients were admitted to the emergency department in the first 24 hours after the onset of sign and symptoms. WBC varied from 8.600 to 30.900/mm3 (median=12.100, IQR=5.7). Ruptured cysts were localised in liver (n=25, 86.2%), in spleen (n=2, 6.89%) or in pelvis (n=2, 6.89%) and diameter varied from 40 to 200 mm (median= 90, IQR=50). Among the cysts ruptured in liver, 19 (76%) of them were localised in right lobe. Among the ruptured cysts of liver, 20 (80%) of them underwent conservative surgery (partial pericystectomy etc), remaining 5 patients (20%) underwent a radical surgical treatment (pericystectomy etc). A biliary orifice was diagnosed during surgical exploration in either cyst cavity or cut surface of liver in 12 (48%) of the patients. Patients with a dilated common bile duct or a visible biliary duct orifice in cystic cavity underwent common bile duct exploration and T-tube drainage procedure (n=6, 24%). One patient died on postoperative day one, due to cardiopulmonary complications secondary to cyst rupture. All along the postopeartive follow-up of median 1416 days, seven (24.1%) patients were diagnosed for diseased recurrence. Intraperitoneal rupture of the hydatid cyst is a life-threatening complication of hydatid cyst disease, for which diagnosis without delay and timing of surgical treatment is essential. Anaphylactic shock cases require rapidly initiation of medical treatment against allergic reactions. Despite scolocidal agents, vesicular spread into peritoneal cavity account for the major risk factor for disease recurrence. Hence, abdominal cavity should be explored cautiously.

Double common bile duct with cholelithiasis.

Double common bile duct is a rare congenital anomaly among biliary anomalies. The anomaly has an important clinical implication because of its association with biliary tract obstruction. In addition, if one of the two common bile ducts is mistaken for the cystic duct during surgery, residual stones and bile duct injury are likely to occur. Here, we report a case of double choledochal variation (Type Vb) with choledochal calculi. An 82-year-old woman was admitted to the hospital due to mild pain in the upper abdomen accompanied by vomiting for 3 days. Magnetic resonance imaging suggested common bile duct lithiasis, variation of the common bile duct and moderate biliary tract dilation. Laparoscopy combined with choledochoscopic lithotomy was performed for choledocholithotomy. During the operation, left and right choledocholithotomy was performed, and all the gallstones were removed via choledochoscope. The patient's post-operative recovery was good, and no recurrence of cholelith had been observed at the time of writing.

CT Evaluation of Long-Term Changes in Common Bile Duct Diameter after Cholecystectomy.

The present study aimed to investigate the frequency and extent of compensatory common bile duct (CBD) dilatation after cholecystectomy, assess the time between cholecystectomy and CBD dilatation, and identify potentially useful CT findings suggestive of obstructive CBD dilatation. This retrospective study included 121 patients without biliary obstruction who underwent multiple CT scans before and after cholecystectomy at a single center between 2009 and 2011. The maximum short-axis diameters of the CBD and intrahepatic duct (IHD) were measured on each CT scan. In addition, the clinical and CT findings of 11 patients who were initially excluded from the study because of CBD stones or periampullary tumors were examined to identify distinguishing features between obstructive and non-obstructive CBD dilatation after cholecystectomy. The mean (standard deviation) short-axis maximum CBD diameter of 121 patients was 5.6 (± 1.9) mm in the axial plane before cholecystectomy but increased to 7.9 (± 2.6) mm after cholecystectomy (p < 0.001). Of the 106 patients with a pre-cholecystectomy axial CBD diameter of < 8 mm, 39 (36.8%) showed CBD dilatation of ≥ 8 mm after cholecystectomy. Six of the 17 patients with longterm (> 2 years) serial follow-up CT scans (35.3%) eventually showed a significant (> 1.5-fold) increase in the axial CBD diameter, all within two years after cholecystectomy. Of the 121 patients without obstruction or related symptoms, only one patient (0.1%) showed IHD dilatation > 3 mm after cholecystectomy. In contrast, all 11 patients with CBD obstruction had abdominal pain and abnormal laboratory indices, and 81.8% (9/11) had significant dilatation of the IHD and CBD. Compensatory non-obstructive CBD dilatation commonly occurs after cholecystectomy to a similar extent as obstructive dilatation. However, the presence of relevant symptoms, significant IHD dilatation, or further CBD dilatation 2-3 years after cholecystectomy should raise suspicion of CBD obstruction.

AN OBSERVATIONAL STUDY ON PREDICTION OF DIFFICULTIES DURING LAPROSCOPIC CHOLECYSTECTOMY IN CASES OF CHOLELITHIASIS BY PREOPERATIVE ULTRASONOGRAPHY

BACKGROUND: Laparoscopic cholecystectomy has become the treatment of choice for cholelithiasis. Some reliable factors are needed to predict difficulties during laparoscopic cholecystectomy. So, our aim was to study various preoperative ultrasonographic parameters which may predict difficulties in performing laparoscopic cholecystectomy. METHOD: One twenty five patients of cholelithiasis admitted for elective laparoscopic cholecystectomy were studied. Preoperative ultrasonographic parameters such as gall bladder(GB) wall thickness, transverse diameter of GB, pericholecystic fluid collection, gall stone mobility, number of stones & size of largest stone, common bile duct(CBD) diameter and emphysematous cholecystitis were given a score of 0 or 1 based on findings being negative or positive respectively. Total score was correlated with the difficulties faced during laparoscopic cholecystectomy. RESULT: Out of 125 cases, 42(33.6%) cases were found to be difficult during laparoscopic cholecystectomy and 6 cases (4.8%) required conversion to open cholecystectomy. GB wall thickness (p value= 0.00001), transverse diameter of GB (p value= 0.001), pericholecystic fluid collection (p value= 0.00001), dilated CBD (p value=0.007), size of stone (p value= 0.007) found to be statistically significant in predicting difficulties during laparoscopic cholecystectomy. Higher the preoperative USG score, higher were the chances of difficult laparoscopic cholecystectomy and conversion to open cholecystectomy. CONCLUSION: Pre operative ultrasonography in the form of a formulated score is a good predictor of difficulties during laparoscopic cholecystectomy.

„Vanishing bile duct syndróm“ ako prejav poliekového poškodenia pečene u pacienta po polytraume

Summary: Vanishing bile duct syndrome is a type of drug-induced cholestatic liver injury that occurs when the body is exposed to drugs or other foreign substances. We hospitalized a 44-year-old, so far healthy, male with gradually developing painless icterus and pruritus of the whole body after severe polytrauma. The patient had previously undergone a complex treatment (antibio tics, antifungals, parenteral nutrition, LMWH). Laboratory tests revealed a several-fold elevation of total and conjugated bilirubin with a 3-fold increase in ALP levels, no signifi cant elevation of transaminases, a decrease in prothrombin time and IgG4 antibody positivity. An MRCP scan was performed revealing irregular intrahepatic bile ducts, a dilated common bile duct and characteristics of primary or secondary sclerosing cholangitis. Further examinations ruled out infectious, metabolic, toxic and oncological causes of hepatopathy. A liver bio psy ruled out both autoimmune hepatitis and IgG4 hepatopathy and displayed images of “vanishing bile duct syndrome” in drug-induced liver injury (DILI). Empirical treatment with high-dose intravenous N-acetylcysteine and other hepatoprotective agents led to a gradual decrease of bilirubin, normalization of coagulation parameters and remission of icterus and clinical complaints. This case report points to a cholestatic type of drug-induced liver injury with histologically confi rmed vanishing bile duct syndrome and the need to think of DILI as one of the causes of the otherwise unexplained hepatopathy. Key words: cholangitis – DILI – hepatopathy – IgG4 – vanishing bile duct syndrome

Ascaris lumbricoides Infestation of Bile Ducts: Case Report

Background: Ascariasis is a common helminthic disease that affects the gastrointestinal tract of human beings and is caused by the Ascaris lumbricoid worm. Most of the time, this parasite resides in the intestinal lumen, but it can occasionally travel to the biliary tract through the ampulla of Vater. The most serious and potentially fatal complication of intestinal ascariasis is biliary ascariasis, which can appear in different ways.&#x0D; Case Report: A non-diabetic, non-alcoholic female reported to the emergency department with a one-day history of abdominal pain and vomiting with worms. The pain began gradually with a score of 7/10 and rapidly deteriorated during the day, reaching 10/10 at the hospital presentation. The patient also had a significant medical history. Before papillotomy, she underwent endoscopic retrograde cholangiopancreatography with the removal of one common bile duct (CBD) stone, but no stent was implanted. She had her laparoscopic cholecystectomy done as well. Laboratory examination revealed normal liver function tests and C-reactive protein. While abdominal ultrasound confirmed the presence of hepatic pericholangitis and on ultrasound imaging, the CBD was found to be enlarged approximately 7 mm in diameter and had a linear tubular structure with centre faint echogenicity and periphery tubularity. The ultimate diagnosis of the patient was cholangitis brought on by Ascaris lumbricoides. After the diagnosis, endoscopic retrograde cholangiopancreatography showed sphincterotomy with CBD dilation. The worm was extracted by grasping it with biopsy forceps and pulled out of the papilla using a balloon catheter. The length of the worm was 18 centimeters.&#x0D; Conclusion: Ascaris is the most frequently occurring disease that can cause biliary complications, such as cholangitis. This case report suggests that cholangitis caused by Ascaris lumbricoides can be successfully treated with the endoscopic approach, indicating that endoscopy could be a viable option to manage ascaris.

Magnetic resonance imagingfollowing the demonstration of a normal common bile duct on ultrasound in children with suspected choledocholithiasis: what is the benefit?

The role of MRI in evaluating children with an in situ gallbladder and suspected choledocholithiasis following a negative or inconclusive US is unclear. To determine whether MRI benefits children with suspected choledocholithiasis and a normal common bile duct (CBD) without stones on US. We conducted a retrospective 10-year review of paired US and MRI (within 10days) in children 18years or younger with suspected choledocholithiasis. With MRI as a reference standard, two reviewers independently evaluated the images for CBD diameter, choledocholithiasis, cholelithiasis and pancreatic edema. Serum lipase was recorded. We calculated exact binomial confidence limits for test positive predictive values (PPVs) and negative predictive values (NPVs) using R library epiR. Of 87 patients (46 female, 41 male; mean age 14years, standard deviation [SD] 4.6years; mean interval between US and MRI 1.6days, SD 1.8days), 55% (48/87) had true-negative US, without CBD dilation/stones confirmed on MRI; 5% (4/87) had false-positive US showing CBD dilatation without stones, not confirmed on MRI; 33% (29/87) had true-positive US, with MRI confirming CBD dilatation; and 7% (6/87) had false-negative US, where MRI revealed CBD stones without dilatation (2 patients) and CBD dilatation with or without stones (4 patients). Patients with false-negative US had persistent or worsening symptoms, pancreatitis or SCD. The overall US false-negative rate was 17% (6/35). Normal-caliber CBD on US without stones had an NPV of 89% (48/54, 95% confidence interval: 0.77-0.96). MRI adds little information in children with a sonographically normal CBD except in the setting of pancreatitis or worsening clinical symptoms.Further evaluation is warranted in children with elevated risk of stone disease.

Establishment of a mouse model for bile duct repair and tissue engineering.

Due to the lack of a suitable model, research on biliary biology is far behind that on other organs. A mouse model of common bile duct (CBD) dilation (BDD) was first established and compared with CBD ligation mice (BDL). Then, in a transplantation experiment, the dilated CBD of recipient BDD mice was injured by making an elliptical incision and repaired by transplanting a bile duct patch from donor BDD mice. Biochemical and histological changes were analyzed and cell proliferation of the bile duct grafts was determined. Slightly dilated and unblocked CBD with a diameter of 2.89±0.76 mm was obtained in BDD mice, while the CBD diameter was 0.51±0.08 mm in the Sham group and 4.71±0.64 mm in the BDL group on day 14 after surgery. The liver damage was very mild in BDD mice compared with BDL mice, proving that the BDD model could be further used for bile duct transplantation. By cross transplanting the bile duct patch from enhanced green fluorescence protein and wild-type BDD mice, it was found that the CBD injury was well repaired and the cells of the bile duct patch were completely replaced by recipient-derived cells at 12 week after the repair operation. α Smooth muscle actin, Ki67 and cytokeratin 19 immunofluorescence staining showed that the proliferation of bile duct epithelial cells and abundant active fibroblasts were found within the bile duct patch during the regeneration process. Therefore, a reliable new mouse model of bile duct injury and repair was successfully established and can be used in the study of biliary repair mechanisms and tissue engineering of biliary ducts.

EUS-guided choledochoduodenostomy using a lumen-apposing metal stent in a patient with preexisting duodenal stent and ascites.

Video 1EUS-guided choledochoduodenostomy using a lumen-apposing metal stent in a patient with preexisting duodenal stent and ascites.

Preferable timing of intraductal ultrasonography during endoscopic retrograde cholangiopancreatography lithotomy: A prospective cohort study.

Intraductal ultrasonography (IDUS) is a highly sensitive and non-invasive detective method that can be used to detect complete calculus clearance during endoscopic retrograde cholangiopancreatography (ERCP). In this study, we examined the preferable timing of IDUS during ERCP lithotomy. From 2017 to 2020, patients with choledocholithiasis were randomized into IDUS-BL (IDUS performed before lithotomy) group, IDUS-ALC (cholangiography and IDUS performed after lithotomy) group, and IDUS-AL group (IDUS performed after lithotomy) group. The influence of IDUS on the accuracy of prejudgment, the incidence of residual stones, the need for repeated lithotomy (RL), and fluoroscopy time were analyzed. A total of 184 patients were enrolled. No residual stones were found during follow-up in any of the three groups. There was no difference in prejudgment accuracy rate on size and number of stones between different groups (all P > 0.05). RL were performed in 5, 9, and 9 cases of IDUS-BL, IDUS-ALC, and IDUS-AL group, respectively (P > 0.05). IDUS-AL group had a shorter fluoroscopy time than the other two groups (1.5 ± 0.6 vs. 2.8 ± 1.2, 2.5 ± 1.0 min, P < 0.05). Incidence of RL was related to the location of calculus [middle or lower part of common bile duct (CBD)], lithotripsy, dilated CBD (2.12 ± 0.46 vs. 1.78 ± 0.40 cm, P < 0.01), and inaccuracy prejudgment. IDUS performed after lithotomy is preferable for shorten fluoroscopy time during ERCP. IDUS is a reliable solution for the stone omission, which may be more valuable for patients with high-risk factors of RL.

An adult choledochocele case presenting with unexplained biliary colic: Awareness of endoscopic feature is important

AbstractType III choledochal cyst (choledochocele) is a rare disease. Therefore, some endoscopists are not familiar with the clinical feature of choledochocele. We present a choledochocele case that was difficult to diagnosed until endoscopic retrograde cholangiopancreatography was performed. A 46‐year‐old Taiwanese gentleman had unexplained biliary colic pain with negative findings of physical examination and normal laboratory tests. Magnetic resonance cholangiopancreatography and endoscopic ultrasonography showed dilation of common bile duct (CBD) about 1.8 cm without choledocholithiasis and a cystic lesion at distal CBD about 0.9 cm. The endoscopy showed a cystic‐like bulging structure above the ampullary orifice. Cholangiography showed cystic enlargement of the intramural bile duct superior to the ampullary orifice after contrast injection. Choledochocele was proved. We performed papillotomy and biopsy of the papilla. Awareness of the endoscopic feature and management strategy of choledochoele is important, which is illustrated in this case report.