Extrahepatic Bile Duct Dilatation Research Articles

Design of an improved percutaneous transhepatic cholangio drainage tube based on MRCP imaging data

Objective: Quantified MRCP imaging data was used as a reference for design and preparation of a modified percutaneous transhepatic cholangio drainage (PTCD) tube. Methods: 3.0 T upper abdominal MR and MRCP imaging data of 2 300 patients treated from July 2015 to July 2020 at the Department of Radiology of the Affiliated Cancer Hospital of Zhengzhou University were screened and a total of 381 patients diagnosed with biliary duct structures were identified. Causative etiologies among these patients included pancreatic adenocarcinoma (pancreatic head), cholangiocarcinoma, ampullary carcinoma, as well as intrahepatic and/or extrahepatic bile duct dilation. An improved PTCD tube was designed based on MRCP quantification of left and right hepatic and common hepatic duct length. Results: In the setting of biliary obstruction caused by malignancy, the distance of the left hepatic duct from its origin to the point of left and right hepatic duct confluence was 15.9±3.8 mm, while the distance of the right hepatic duct from its origin to the point of left and right hepatic duct confluence was 12.4±3.2 mm; the length of the bile duct from its origin to the point of left and right hepatic duct confluence was 34.0±8.1 mm. The improved PTCD tube design incorporated an altered length of the drainage orifice. Conclusion: MRCP imaging of the biliary tract is effective for measuring biliary tract length in the setting of pathological dilation. Based on our biliary tract measurements, a modified PTCD tube was designed to more effectively meet drainage requirements and manage biliary obstruction caused by Bismuth-Corlette type Ⅱ and Ⅲ malignancies.

Mesalamine induced hepatotoxicity. Is mesalamine safe?

Dear Editor: Mesalamine is a medication used widely in the treatment of patients with inflammatory bowel disease. Although mesalamine is considered safe, hepatotoxicity has been reported with an incidence of 0-4%. We present the clinical picture of a patient with hepatotoxicity due to mesalamine. A 79-year-old woman in the context of chronic diarrhea, a left-sided ulcerative colitis diagnosis was made, and treatment was initiated with oral mesalamine 4 g per day, and mesalamine suppositories. Before starting treatment, she had normal liver test results. After three months, she presented with headache, fatigue, and intermittent low fever. Her laboratory tests showed a liver profile with a cholestatic pattern, and elevation of inflammatory parameters. Mesalamine was suspended, and an extensive study was performed. Cholangioresonance reported intra and extrahepatic bile duct dilation without obstruction, and thickening of the intrahepatic bile duct. She progressed with worsening of the liver profile without signs of liver failure. A liver biopsy was performed, which showed chronic non-suppurative cholangitis with granulomas and focal concentric fibrosis related to medium-caliber bile ducts, and IgG4 stain was negative.

Gastric cancer simultaneously complicated with extrahepatic bile duct metastasis and portal vein tumor thrombus: a case report

BackgroundGastric cancer metastatic to the extrahepatic bile duct or accompanied by portal vein tumor thrombus (PVTT) is rare. To our knowledge, there have been no cases complicated with both of these factors.Case presentationA 72-year-old man presented with icterus and melena. A biochemical blood test showed abnormal values for hepatobiliary enzymes and a tumor marker, and abdominal computed tomography scan revealed wall thickening of the lower bile duct with intra- and extra-hepatic bile duct dilatation and PVTT. A biopsy of the lower bile duct during endoscopic retrograde cholangiopancreatography demonstrated a moderately differentiated tubular adenocarcinoma. Moreover, gastroduodenoscopy showed a type 3 tumor at the lesser curvature of the gastric antrum, and an endoscopic biopsy demonstrated a moderately differentiated tubular adenocarcinoma. We diagnosed concomitant gastric cancer and distal bile duct accompanied by PVTT, and pancreatoduodenectomy with combined resection of the portal vein was performed. The resected specimen revealed a tumor in the lesser curvature of the gastric antrum and circumferential wall thickening in the lower bile duct. In pathological findings, infiltration of a moderately differentiated tubular adenocarcinoma from the mucosal layer to the subserosal layer of the stomach was observed. In contrast, a moderately differentiated tubular adenocarcinoma demonstrating the same histological type as the gastric cancer had spread not to the mucosal layer but mainly to the fibromuscular layer of the lower bile duct. Immunohistochemical staining showed identical patterns between gastric cancer and the bile duct tumor: negativity for cytokeratin 7 (CK7), and positivity for CK19 and 20. Therefore, the final diagnosis was extrahepatic bile duct metastasis from gastric cancer with PVTT. Unfortunately, multiple liver metastases occurred in the early postoperative period and chemotherapy was conducted, but the patient died 12 months after the surgery.ConclusionsIn the diagnosis of extrahepatic bile duct metastasis, immunohistochemical staining of gastric cancer and the bile duct tumor was essential and helpful as decisive evidence.

The role of various laboratory parameters associated with obstructive cholestatic jaundice in pancreatic tumor: A case report and literature review

Introduction: Obstructive jaundice can be caused by pancreatic cancer, where most tumors block bilirubin excretion, and excess bilirubin accumulation causes jaundice. Jaundice occurs in more than 65% of pancreatic cancer patients. Jaundice is caused by the location of the tumor, usually located in the head of the pancreas, suppressing the bile ducts and creating a blockage characterized by an increase in bilirubin, especially direct bilirubin. Aspartate transaminase (AST) and alanine transaminase (ALT) may also be elevated in pancreatic cancer patients but to a lesser extent. Case Presentation: A 63-year-old male patient presented with ocular symptoms and generalized jaundice that had lasted for 2 months. Patients also complain of a bloated stomach and feel thin due to continued weight loss. The patient's stool was the color of putty and brown, like viscous urine. A physical examination revealed conjunctival jaundice in both eyes and hepatomegaly. Abdominal ultrasonography (USG) results suggest a pancreatic head mass with a dilated pancreatic duct and edema of the gallbladder with dilated extrahepatic bile duct (EHBD). Laboratory tests showed that the patient had elevated liver function, total bilirubin 11.90 mg/dl, direct bilirubin 8.29 mg/dl, SGOT 33 U/l, SGPT 54 U/l, and three positive urinary bilirubin values. It became clear that. The patient was diagnosed by observing cholestatic jaundice and the differential diagnosis of suspected pancreatic cancer of the head and cholangiocarcinoma. Conclusion: Examining laboratory parameters such as total bilirubin, especially direct bilirubin, liver enzymes SGOT, and SGPT may help localize obstructions, such as those caused by pancreatic tumors causing post hepatic obstructive jaundice.

Large Element de novo Choledocholithiasis: A case report

The case is a female 73 years old, with a history of laparoscopic cholecystectomy ten years ago, and is diagnosed with de novo choledocholithiasis. The medical staff conducted two Endoscopic Retrograde CholangioPancreatographies (ERCP). The results of the first one were unresolved choledocholithiasis, endoscopic sphincterotomy, intra and extrahepatic bile duct dilation, and plastic biliary prosthesis placement. In the second one, the results showed an ampulla of Vater with endoprosthesis in situ, which was removed easily. Besides, it was tried to trap the stone with a basket, without success due to dimensions (>45 mm). A Tannenbaum-type biliary stent was placed to ensure biliary drainage. After, the patient was scheduled for a laparoscopic bile duct exploration, and dissection was performed during the surgical procedure until locating a dilated common bile duct of approximately 3 cm. The stone was removed with laparoscopic forceps. Choledochorrhaphy was performed, and a drain was placed.

An Unusual Case of Intermittent Fever With Multiple Liver Lesions

Question: A 46-year-old man with a history of hypertension presented to our hospital with a chief compliant of intermittent fever for 2 weeks. He denied a history of nausea, vomiting, abdominal pain, diarrhea, abdominal distention, loss of appetite, or weight loss. Physical examination on admission was unremarkable. Laboratory studies showed white blood cells 15.32 × 109/L (reference 3.5–9.5 × 109/L) with 38.3% (reference 0.4%–8.0%) eosinophils, C-reactive protein 49.72 mg/L (reference 0–10 mg/L), and erythrocyte sedimentation rate 44 mm/h (reference 0–15 mm/h). No parasite eggs or larvae were found in microscopic examination of direct smears of the stool. Liver function tests revealed alanine transaminase 50.5 IU/L (reference 9–50 IU/L), alkaline phosphatase 134 IU/L (reference 15–40 IU/L), gamma-glutamyltransferase 224 IU/L (reference 10–60 IU/L), total protein 40.1 g/L (reference 65–85 g/L), and albumin 21.6 g/L (reference 40–55 g/L). His renal function and tumor markers, such as alpha-fetoprotein, carcino-embryonic antigen, and carbohydrate antigen 19-9 were all within normal ranges. Tests for hepatitis B, hepatitis C, antinuclear antibodies, extractable nuclear antigen antibodies, and anti–neutrophil cytoplasm antibodies were all negative. No significant abnormalities were detected on electrocardiography, echocardiography, and chest computed tomography (CT). Routine ultrasound revealed multiple hypoechoic areas with unclear borders in the left lobe and right posterior lobe of the liver. Magnetic resonance imaging (MRI) of the liver was subsequently performed and showed multiple nodular or clumpy lesions as low signal intensity on T1-weighted imaging (WI) (Figure A) and high signal intensity on fat-suppressed T2-WI (Figure B) and diffusion WI (Figure C). Contrast-enhanced scan exhibited slightly heterogeneous enhancement (Figure D) or annular enhancement (Figure E). MRI did not indicate any anatomic malformations or intrahepatic or extrahepatic bile duct dilation. Positron emission tomography–computed tomography (PET-CT) revealed increased 18F-fluorodeoxyglucose uptake in the liver lesions (maximum standardized uptake value 3.8–5.2) (Figure F). The patient subsequently underwent CT-guided liver biopsy. Histopathology demonstrated chronic hepatic inflammation with prominent eosinophilic infiltration in portal areas and some acinar areas (Figure G).

Role of endoscopic ultrasound in the evaluation of unexplained extrahepatic bile duct dilatation.

This study was performed to assess the diagnostic performance of endoscopic ultrasonography (EUS) in patients with extrahepatic bile duct (EBD) dilatation and develop a novel model incorporating EUS-based signature with clinical parameters for distinguishing the malignant dilation of EBD. The EUS data and clinical parameters of the patients were collected and analyzed retrospectively. First, we evaluated the diagnostic performance of EUS in detecting the cause of EBD dilatation. Then, we performed univariate and multivariate binary logistic regression analyses based on clinical and EUS features. Finally, a nomogram was established to aid in distinguishing between malignant dilation and noncalculous benign dilatation of EBD in patients. A total of 184 patients were enrolled. For the diagnosis of malignant dilation, EUS achieved an accuracy of 90.76%, sensitivity of 85.96%, and specificity of 92.91%. For the diagnosis of calculous dilation, EUS achieved an accuracy of 100%, sensitivity of 100%, and specificity of 100%. For the diagnosis of noncalculous benign dilatation, EUS achieved an accuracy of 90.76%, sensitivity of 90.90%, and specificity of 90.58%. Multivariable logistic regression analyses indicated that abnormal liver function test, elevated tumor markers, and EUS findings were the well-diagnostic factors of malignant EBD dilation. The nomogram established by these factors showed good calibration and discrimination. EUS is a useful examinational modality in the work-up of EBD dilatation. In combination with abnormal liver function test and elevated tumor markers, EUS may provide additional information for the detection of malignant dilation of EBD and should be further investigated.

Endoscopic ultrasound-guided antegrade stenting for benign biliary disease in an elderly patient with altered anatomy (Roux-en-Y).

A 91-year-old man with multiple pathologies and a history of subtotal gastrectomy with Roux-en-Y reconstruction for an antral ulcer was admitted with acute cholangitis. A hepatobiliary magnetic resonance imaging (MRI) scan showed multiple choledochal stones causing intra- and extrahepatic bile duct dilatation.

S1907 A Rare Case of Type 1 Choledochal Cyst With Type C Anomalous Pancreaticobiliary Maljunction in a 52-Year-Old Patient

Introduction: Choledochal cysts are rare anomalies of the bile duct that generally present in childhood but can rarely be delayed until adulthood in 20% of cases. They are often diagnosed incidentally or present with acute pancreatitis or cholangitis. We report a case of a type 1 choledochal cyst (T1CC) and type C anomalous pancreaticobiliary maljunction (PBM), successfully managed by a multidisciplinary approach. Case Description/Methods: A 52-year-old woman presented with right upper quadrant pain, jaundice and vomiting. Labs revealed elevated lipase, bilirubin, AST, ALT and alkaline phosphatase. A CT of the abdomen showed no gallstones but a marked dilation of extrahepatic bile duct with a transition point in the distal intrapancreatic portion (Figure a). An endoscopic retrograde cholangiopancreaticogram (ERCP) showed fusiform dilation of the CBD consistent with T1CC (Figure b). Spyglass cholangioscopy revealed focal stenosis in the distal CBD joining above the ventral pancreatic duct opening within the long common channel, suggestive of type C anomalous PBM (Figure c). A plastic biliary stent was placed into the CBD. EUS guided fine needle biopsy of the stricture showed no evidence of malignancy. Her clinical course was complicated by multiple admissions due to stent occlusion. After multidisciplinary discussion, the patient underwent choledochal cyst resection with hepaticojejunostomy, cholecystectomy and biliary reconstruction. Intraoperative gallbladder specimen revealed poorly differentiated adenocarcinoma with plan for chemotherapy. Discussion: Choledochal cysts are a rare congenital anomaly characterized by enlargement of the CBD. There are five types of choledochal cysts (Table). Etiology remains unclear and while some believe these cysts are congenital in nature, others propose they arise from anomalous PBM. PBM is defined as congenital malformation in which the pancreatic and bile duct join outside the duodenal wall forming a long common channel. This leads to reflux of biliary secretions leading to chronic inflammation, increasing the risk of developing cholangiocarcinoma and gallbladder cancer, as seen in our patient. Placement of biliary stents can temporarily alleviate symptoms, but surgical excision is the definitive treatment. Our case highlights the importance of including type 1 choledochal cyst in the differential diagnosis even in adult patients with a significantly dilated CBD. A thorough endoscopic and radiological work up should be done to prevent progression to malignancy.Figure 1.: A. CT of the abdomen showing marked dilatation of extrahepatic bile duct with a transition point in the distal intrapancreatic portion. B. Cholangiogram showing Type 1 Choledochal Cyst and Type C Anomalous Pancreaticobiliary Maljunction. C. Spyglass cholangioscopy showing JagwireTM within the CBD (yellow arrow) revealing focal stenotic CBD joining the common channel just above the ventral pancreatic duct (blue arrow). Table 1. - Types of Choledochal Cysts Type Description Type I Fusiform dilation of the CBD Type II Bile duct diverticulum Type III Saccular dilation of the intraduodenal portion of the CBD Type IVa Multiple cysts at intra and extrahepatic ducts Type IVb Multiple cysts at extrahepatic ducts only Type V Fusiform or saccular cystic dilation of the intrahepatic bile duct

S3167 Sickle Cell Hepatopathy in a Young Patient With Markedly Elevated Bilirubin

Introduction: The vaso-occlusive events that characterize a sickle cell pain crisis are known to affect multiple organ systems. Sickling in the hepatic sinusoids leads to ischemia, cholestasis, and sequestration, which collectively contribute to acute liver dysfunction often referred to as sickle cell hepatopathy (SCH). As one of the rarer complications of sickle cell disease (SCD) SCH may go under-recognized. Here we present a case of acute sickle cell hepatic crisis, a subset of SCH, with the aim of increasing the available literature on this important topic. Case Description/Methods: A 20-year-old male with a history of sickle cell disease (SCD) presented for evaluation of right upper quadrant abdominal pain. Vitals signs were normal and physical examination was notable for jaundice and right upper quadrant abdominal tenderness. Labs revealed mildly elevated liver enzymes and elevated direct bilirubin of 34 mg/dL. Abdominal sonography revealed findings suggestive of hepatitis and common bile duct dilation, with suggestion of gallbladder wall thickening. MRCP showed mild intrahepatic and extrahepatic bile duct dilation, as well as splenic hemosiderosis. The common bile duct was 0.9 cm in diameter. Hepatitis A, B, C, as well as HIV, CMV, and herpes screening tests were nonreactive. An ultrasound-guided liver biopsy then revealed features of an acute sickle cell hepatic crisis, including distended sinusoids with erythrocyte sludging. With two days of symptomatic treatment alone, the patient had improvement in his direct bilirubin to 7 mg/dL and was discharged after complete resolution of his symptoms. (Figure) Discussion: Acute sickle cell hepatic crisis (ASCHC), a subset of sickle cell hepatopathy (SCH), is often difficult to diagnose for a multitude of reasons including vague presenting symptoms and clinician unfamiliarity with the disease. While treatment guidelines are lacking with regards to the specific treatment for ASCHC, it is worth noting that in our case clinical and assay improvement was seen after several days of symptomatic treatment alone. Although not present in our case, ASCHC has the potential to be concurrent with a more severe form of the disease known as sickle cell intrahepatic cholestasis (SCIC), which if untreated can be fatal. Both ASCHC and SCIC can present with jaundice, as in our patient, but only SCIC progresses to organ failure. As more cases are described, the optimal treatment modalities for these rarer complications of sickle cell disease will only increase.Figure 1.: Liver parenchyma with dilated sinusoids, readily visualized sickled red blood cells (right side of the image) and canalicular cholestasis (brown pigment on the left side of the image).

S2919 Bile Duct Injury Due to Ketamine Use

Introduction: Ketamine is used routinely in the hospital for anesthesia, but is also used recreationally for its hallucinogenic and dissociative side effects. Chronic recreational use has been linked to bile duct damage and ulcerative cystitis. We report a case of ketamine induced sclerosing cholangiopathy. Case Description/Methods: A 42-year-old Cantonese woman with past medical history of bilateral hydronephrosis with stents leading to chronic kidney disease presented with abdominal pain associated with abnormal transaminases. Alkaline phosphatase was high at 1,017 IU/L with gamma glutamyl transferase of 2,310 IU/L with normal bilirubin. Abdominal imaging showed diffuse dilatation of the common bile duct. Viral serologies and anti-mitochondrial antibody were negative. She reported chronically elevated liver tests of unknown etiology. Social history was notable for prior alcohol abuse. She denied family history of liver diseases. Her pain resolved and plan was for outpatient follow-up, but she re-presented with sepsis with a rise in bilirubin to 2.9 mg/dL (Table 1). Given prior abnormal imaging, a magnetic resonance cholangiopancreatography was obtained, which showed increased intra- and extrahepatic bile duct dilation with irregular appearance of the central intrahepatic ducts with possible stricture. Differential diagnoses were recurrent pyogenic cholangitis, sclerosing cholangitis, and IgG4 disease. Her IgG level was high at 2,779 mg/dL with IgG4 elevated at 213 mg/dL. Liver biopsy showed chronic cholestatic liver injury consistent with sclerosing cholangitis (Image 1). IgG4 stain was negative. Upon further investigation, patient admitted to at least a decade of daily ketamine use, which was likely the culprit of both her kidney and liver diseases. Discussion: Due to her age, race, gender and rarity of ketamine induced cholangiopathy, she was not directly asked about ketamine use. Since the early 2000s, ketamine has emerged as the illicit drug of choice in Hong Kong and has seen increased use throughout Asia. The biliary damage from ketamine has been studied by a Chinese group that found 62% of the 257 chronic ketamine users had biliary tract anomalies. The greater the alkaline phosphatase, the higher the likelihood of finding biliary tract anomalies on imaging. Ketamine cessation has resulted in normalization of liver tests and imaging, however worsening cholangiopathy has been seen despite abstinence. In patients who present with unexplained cholangiopathy, chronic ketamine use should be considered.Figure 1.: Liver biopsy: A mild lymphoplasmacytic inflammation is noted in some triads with focal and mild interface activity. The bile ducts are injured (irregular contour, unevenly distributed nuclei, intracytoplasmic vacuoles) with focal periportal cholestasis. Immunohistochemical stain for keratin 7 confirms predominantly periportal cholestatic hepatocytes. Keratin 19 shows widespread loss of canals of Hering and focal bile duct loss. Rhodanine stain confirms periportal hepatocellular copper accumulation compatible with a chronic cholestatic process. Table 1. - Patient's hepatic function panels during initial encounter, subsequent encounter, and at least 6 months after subsequent encounter Liver Tests Reference Range & Units Initial Hospitalization Subsequent Hospitalization Most Recent Liver Tests Total bilirubin 0.2 – 1.2 mg/dL 0.8 2.9 4.5 Direct bilirubin 0 – 0.5 mg/dL 0.7 1.8 3.3 Aspartate aminotransferase 5 – 34 IU/L 75 104 88 Alanine transaminase 0 – 37 IU/L 74 129 91 Alkaline phosphatase 40 – 150 IU/L 1017 1106 845 Gamma glutamyl transferase 12 – 43 IU/L 2310 2516 1897

S1740 Hematochezia Due to Cholecystocolonic Fistula and Gallstone in the Transverse Colon

Introduction: We present this case, because cholecystocolonic fistulas are rare, accounting for less than 30% of all cholecystoenteric fistulas. This case emphasizes the unique finding of a rare fistula and the importance of sound clinical judgement for timely diagnosis and follow-up, despite the atypical presentation of the patient. Case Description/Methods: The patient is a 65-year-old man, with a history of hypertension, hereditary spherocytosis, alcohol-related cirrhosis (MELD-Na of 20) with prior non-bleeding esophageal varices, who presented with hematochezia. He reported 3 episodes of gross bloody stools for one day, and denied hematemesis and abdominal pain. Seven years prior to this admission, he had a history of choledocholithiasis and presented with painless jaundice. At that time, he underwent an endoscopic retrograde cholangiopancreatography with sphincterotomy and biliary stent placement. On admission, he was vitally stable. His labs were the following: Hgb 8.3 g/dL (baseline of 12.7 g/dL a year prior to presentation), BUN 6 mg/dL, Cr 0.7 mg/dL, INR 1.4, ALP 108 IU/L, ALT 19 IU/L, AST 41 IU/L, total bilirubin 3.3 mg/dL, and direct bilirubin 1.7 mg/dL. Due to concern for bleeding, both an esophagoduodenoscopy (EGD) and colonoscopy were obtained. The EGD showed portal hypertensive gastropathy without significant source of bleeding. The colonoscopy revealed a 2 cm gallstone surrounded by friable mucosa at the proximal transverse colon. Further work-up with a CT abdomen showed a fistula connecting the gallbladder and transverse colon, presence of a stone in the gallbladder, and pneumobilia, with no intrahepatic or extrahepatic bile duct dilation (Figure). The gallstone lead to mucosal irritation and hematochezia. With the image confirmed cholecystocolonic fistula as the cause of the gallstone in the transverse colon, general surgery recommended conservative management given the resolution of the patient’s hematochezia and his poor surgical candidacy. On follow-up, patient had no further bleeding. Discussion: Cholecystocolonic fistulas are typically a rare complication of cholelithiasis with cholecystitis, are commonly reported in the sigmoid colon, and commonly lead to gallstone ileus and bleeding. Although these fistulas are typically challenging to diagnose given non-specific symptoms and although our patient presented with a fistula in the transverse colon and no cholecystitis, sound correlation of reported history with labs, procedures, and imaging lead to timely diagnosis and appropriate follow-up.Figure 1.: The CT abdomen and pelvis shows the area of the cholecystocolonic fistula with gallstone in the gallbladder (both marked with red arrow), and pneumobilia.

S1886 A Case Report of Iatrogenic Common Bile Duct Stricture

Introduction: Iatrogenic bile duct injuries (IBDIs) are common postsurgical complications following cholecystectomy. IBDI vary from a minor bile leakage to biliary stricture or a complete occlusion of the common bile duct. The authors report a case of a common bile duct stricture caused by suture material after an open cholecystectomy. Case Description/Methods: A 57-year-old male with history of NAFLD presented with acute onset of severe epigastric abdominal pain, nausea and vomiting. Lipase was elevated. CT scan of the abdomen/pelvis revealed gallbladder wall thickening and dilated extrahepatic bile ducts consistent with cholecystitis and biliary obstruction. The patient underwent an open partial fenestrated cholecystectomy which was complicated by injury of the gastric antrum requiring primary two-layered repair and omental patching. ERCP was not performed due to gastric injury. His symptoms improved and he was discharged home. One month later he returned with severe epigastric pain. Initial work-up revealed elevated lipase and transaminases. CT of the abdomen/pelvis showed peripancreatic fluid and fat stranding with persistent mild biliary dilatation. MRCP identified three choledocholiths at the level of the ampulla. ERCP was performed with sphincterotomy, balloon extraction of several stones and sludge, and placement of a plastic biliary stent. There was an area of resistance felt during balloon sweep. He was discharged after symptom resolution with recommendations to repeat ERCP in 6 weeks for stent removal. A repeat ERCP revealed persistent area of resistance with filling defect on fluoroscopy. (Figure). A spyglass revealed a suture material and mild inflammation in the CBD at the cystic duct takeoff (Figure). Stone formation induced by suture material is thought to be the culprit of the recurrent acute pancreatitis. Discussion: IBDIs account for the majority of postsurgical complications after cholecystectomy. The incidence of IBDIs is higher in laparoscopic cholecystectomy when compared to open cholecystectomy. IBDIs are associated with significant perioperative morbidity, mortality, and prolonged hospital stay. If left untreated, they can result in life-threatening complications such as cholangitis, secondary biliary cirrhosis, and portal hypertension. One of the uncommon postoperative complications is stone formation induced by suture material used in cystic duct ligature. Surgical sutures can function as a nidus for crystallization leading to obstruction and development of large choledocholiths.Figure 1.: Top. ERCP shows filling defect in the common bile duct. Bottom: Spyglass shows suture material and adjacent mild imflammation of the CBD at the systic duct takeoff.

Effect of Deep Learning-based Contrast-enhanced CT Image Reconstruction on the Image Quality of the Biliary System

Objective To evaluate the effect of a deep learning reconstruction (DLR) method on the visibility of contrast-enhanced CT images of the biliary system by comparing it with different iterative reconstruction algorithms including the adaptive iterative dose reduction 3D (AIDR 3D) algorithm,forward projected model based iterative reconstruction solution (FIRST),and filtered back projection (FBP) algorithm. Methods A total of 30 patients subjected to abdominal contrast-enhanced CT and diagnosed with dilatation of common bile duct or extrahepatic bile duct were retrospectively included in this study.The images of the portal phase were reconstructed via four different algorithms (FBP,AIDR 3D,FIRST,and DLR).Signal to noise ratio (SNR) and contrast to noise ratio (CNR) of the dilated bile duct,liver parenchyma,measurable bile duct lesions,and image noise were compared between the four datasets.In subjective analyses,two radiologists independently scored the image quality (best:4 points,second:3 points;third:2 points;fourth:1 point) of the four datasets based on the noise and image visual quality of the biliary system.The Friedman and the Bonferroni-Dunn post-hoc tests were performed for comparison. Results The DLR images (bile duct:4.42±0.87;liver parenchyma:3.78±1.47) yielded higher CNR than the FBP (bile duct:2.21±1.02,P<0.001;liver parenchyma:1.43±1.29,P<0.001),AIDR 3D (bile duct:2.81±0.91,P=0.024;liver parenchyma:2.39±1.94,P=0.278),and FIRST (bile duct:2.51±1.24,P<0.001;liver parenchyma:2.45±1.81,P=0.003) images.Furthermore,the DLR images had higher SNR (bile duct:1.39±0.85,liver parenchyma:9.75±1.90) than the FBP (bile duct:0.86±0.63,P<0.001;liver parenchyma:3.31±1.12,P<0.001) and FIRST (bile duct:1.01±0.61,P=0.013;liver parenchyma:5.73±1.37,P<0.001) images,and showed lower noise (10.51±3.53) than the FBP(4.10±3.92,P<0.001),AIDR 3D (15.72±2.41,P=0.032),and FIRST (17.20±3.82,P<0.001) images.SNR and CNR showed no significant differences between FIRST and AIDR 3D images (all P>0.05).DLR images [4(4,4)] obtained higher score than FPB [1(1,1),P<0.001],AIDR3D[3 (2,3),P=0.029],and FIRST[2 (2,3),P<0.001] images. Conclusion DLR algorithm improved the subjective and objective quality of the contrast-enhanced CT image of the biliary system.

10-year-old Boy with Giant Choledochal Cyst: A Case Report

Choledochal duct cyst is a rare congenital anomaly in the form of cystic dilatation of both intrahepatic and extrahepatic bile ducts. The clinical symptoms of choledochal cysts are generally due to bile stasis, stone formation, recurrent superinfection, and inflammation. This case depicts a 10-year-old boy presented with a chief complaint of an enlarged abdomen that was rapidly growing, sub-febrile fever and yellowing of the sclera. A choledochal duct cyst was shown in the abdominal ultrasonography. Laboratory examination showed an increase in liver function test, hypoalbuminemia, and prolonged coagulation profile. Magnetic resonance cholangiopancreatography showed a significant cystic dilatation of the common bile duct extending to the common hepatic duct. Surgery was performed twice, first to drain the cyst and second to perform complete excision and anastomoses to the jejunum, as fluid continued to refill the cyst.

Development and validation of a novel porcine bile duct dilation model for EUS training.

Background and study aims Image-guided minimally invasive techniques have transformed the management of malignant and benign bile duct obstructions. These evolving techniques are being widely adopted and applied and hands-on training using high quality models is required to improve the proficiency of practitioners. This experimental study aimed to validate an in vivo porcine model created to simulate bile duct dilation for interventional endoscopic ultrasound (EUS) hands-on training curriculums. Materials and methods Thirty-six porcine models were involved and the procedures were performed in an experimental hybrid operating room under general anesthesia. Animals underwent endoscopic duodenal papilla clipping with several hemostatic metallic clips. After a survival period of 24 to 48 hours, the models with effective intrahepatic and extrahepatic bile duct dilatation were included in the hands-on training. Trainees and faculty were given structured evaluations of the model realism and usefulness. Results Extrahepatic bile duct and gallbladder dilation was achieved in all 36 of the models, and in 11 of the 36 models, a treatable intrahepatic duct dilatation was achieved. During the hands-on training, EUS-guided biliary drainage, EUS-guided transgastric gallbladder drainage, and EUS through-the-needle microbiopsy forceps procedures were feasible. Overall, 75 % of the experts and trainees evaluated the training as excellent. Conclusions We present a minimally invasive, reliable and time- effective model of extrahepatic dilation suitable for interventions. The model was less effective for intrahepatic ducts, which should be considered if intrahepatic biliary dilation is required for training.

Pancreatic tuberculosis mimicking a neoplastic mass in an immunosuppressed patient who also presented adenopathy syndrome: Case report

Pancreatic tuberculosis is unusual, with an incidence reported to be less than 4,7% worldwide. We report the case of a 32-year-old man recently diagnosed with HIV whose adenopathy syndrome was understudy. Lymph node cervical and bone marrow biopsies were performed without evidence of neoplastic infiltration, fungal infection, or tuberculosis. He arrived at the emergency room for acute band abdominal pain radiating to the back. Contrast-enhanced abdominal computed tomography revealed a mass in the head of the pancreas which generates intra- and extrahepatic bile duct dilation. Serial sputum, PPD, Genexpert, bronchoscopy and ultrasound fine needle aspiration biopsy were negative for tuberculosis, with no evidence of microorganisms or malignancy; cultures results pending. A second biopsy was requested using a No. 19 needle reporting a necrotizing process with acid-fast bacilli, compatible with tuberculosis, and the pending cultures results were positive for the mycobacterium tuberculosis complex, confirming the diagnosis. Clinical awareness of pancreatic tuberculosis in immunosuppressed patients in our country, may lead to faster and accurate diagnosis study and management, using minimally invasive techniques as diagnostic tools.

GLUCOGENOSIS AS A CAUSE OF INTRAHEPATIC CHOLESTASIS

Hepatic glycogen storage pathologies are very rare diseases among inborn errors of metabolism caused by the alteration of the enzymes involved in the metabolism of glycogen. GSDs are classified according to enzyme deficiency and affected tissue, including types 0, Ia, Ib, III, IV, VI, and XI. The clinical presentation can be very varied, including intolerance to fasting, growth retardation and hepatomegaly. It can present with hypoglycemia, hyperlactatemia, increased liver enzymes, and hyperlipidemia. The most common type of glycogen storage disease is GDS IX, its incidence is 1: 100,000 births and it is responsible for 25% of all cases. The most common GSD IX subtype is subtype IX a caused by mutations in PHKA2, which accounts for 75% of cases. Long-term complications include liver adenomas, kidney disease, cardiomyopathy, and muscle symptoms. 27-year-old male patient. Important history, positive smoking with IT 1, positive alcoholism with consumption of 8 grams of alcohol per day for 10 years. During childhood, he presented hepatomegaly and an isolated event of jaundice. He began his condition one month before with asthenia, adynamia and weight loss (9 kg / 30 days), accompanied by generalized jaundice, later he presented abdominal pain in the right upper quadrant, with early satiety, acholia and choluria. On physical examination: hepatosplenomegaly, jaundice of the skin and integuments. Paraclinical: BT: 5.3 mg / dl, BD: 1.2 mg / dl 8, DHL: 444IU / L, TGP: 89 U / L, TGO: 168 U / L FA: 1050 U / L. HIV: non-reactive, HBV HCV non-reactive. Ultrasound with multiple nodular echogenic lesions without bile duct dilation, a 1.8 mm common bile duct, a 7 mm portal vein, and an enlarged spleen. Endoscopy: portal hypertensive gastropathy, extrinsic compression of the body and gastric fundus without evidence of varicose veins. Cholangioresonance without intra- and extra-hepatic bile duct dilation. Normal alpha 1 antitrypsin (2.08 g / dl). Given the evidence of intrahepatic cholestasis, it was decided to perform an ultrasound-guided liver biopsy where it was observed positive for intracytoplasmic glycogen in the hepatocytes, thus establishing a definitive diagnosis of Glycogenosis. Due to its low incidence, the diagnostic approach of Glycogenosis presents a challenge. The diagnosis is made at an early age; the clinical data will depend on the affected tissue and type of Glycogenosis. The histopathological report is the mainstay of diagnosis in this type of case and making a differential diagnosis with other entities and a genetic study. Glycogen storage disorders are part of a group of rare and few suspected pathologies. It is not frequent to find them in adult patients due to their complications. The prognosis must be individualized based on the affected tissue and the subtype presented. The authors declare that there is no conflict of interest.

Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) abdominal pain in patients without post-ERCP pancreatitis

BackgroundAbdominal pain is often observed after endoscopic retrograde cholangiopancreatography (ERCP). Few studies have focused on the risk factors of post-ERCP abdominal pain without post-ERCP pancreatitis (PEP). This study aimed to identify risk factors of post-ERCP abdominal pain without PEP and investigate characteristics of the abdominal pain in non-PEP patients. MethodsData from patients who underwent ERCP from August 2019 to January 2020 were retrospectively collected. Characteristics of the abdominal pain after ERCP were recorded and compared between PEP and non-PEP patients. Multivariate analysis was conducted to identify risk factors of non-PEP abdominal pain. ResultsA total of 1295 ERCP procedures were investigated in this study, among which 100 (7.72%) patients presented post-ERCP abdominal pain without PEP and 63 (4.86%) patients with PEP. Multivariate analysis found 9 risk factors of non-PEP abdominal pain: age ≤ 65 years [odds ratio (OR): 1.971], primary ERCP (OR: 2.442), dilated extrahepatic bile duct (OR: 1.803), no papilla opening (OR: 2.095), pancreatic guidewire passages (OR: 2.258), white blood cells (WBC) ≤ 6.0 × 109/L (OR: 1.689), platelet (PLT) ≤ 250 × 109/L (OR: 2.505), serum γ-glutamyl transferase (γ − GT) ≤ 35 U/L (OR: 2.190), and albumin ≥ 40 g/L (OR: 1.762). The PEP group had later pain onset, higher pain frequency and longer hospital stay than those of the non-PEP pain group (P < 0.05). There were no significant differences in the pain duration, visual analogue scale score and mortality between the PEP group and non-PEP pain group (P > 0.05). ConclusionsThis study indicated that age ≤ 65 years, primary ERCP, dilated extrahepatic bile duct, no papilla opening, pancreatic guidewire passages, lower WBC, lower PLT, normal γ − GT and elevated albumin were independent risk factors for post-ERCP abdominal pain without PEP. The pain occurred earlier in non-PEP patients than in PEP patients.

Focal IgG4-related autoimmune pancreatitis with distal choledochal adenocarcinoma: a rare case report

BackgroundAutoimmune pancreatitis (AIP) is a rare disease that manifests as pancreatic involvement in systemic IgG4-related disease (IgG4-RD), a special type of chronic pancreatitis caused by autoimmune abnormalities. The main imaging manifestations of IgG4-related AIP consist of diffuse or localized pancreatic enlargement and irregular pancreatic duct narrowing. The diagnosis of AIP is challenging because it can present with focal lesions, similar to radiologically bile duct cancer or pancreatic cancer.Case presentationA 55-year-old male patient was admitted with painless jaundice and multiple radiographic findings of pancreatic head mass, as well as intrahepatic and extrahepatic bile duct dilatation. Various imaging methods indicated pancreatic cancer. However, the endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) and a laparoscopic pancreatic biopsy suggested an IgG4-related AIP. After one month, magnetic resonance imaging showed that the lesion had slightly grown. Combined with CA19-9 and other indexes, the possibility of malignancy was high and there were still surgical indications. The pathological analysis following a pancreaticoduodenectomy revealed poorly differentiated adenocarcinoma in the distal common bile duct.ConclusionTo date, few reports have described pancreatic or extrapancreatic malignancies in AIP patients, and no association between AIP and bile duct adenocarcinoma has been previously confirmed. This case discuss the differentiation between AIP and malignancy, recent research progress, and the correlation between the two diseases, highlights the importance of carefully evaluating patients with AIP to rule out potential tumors, as well as the critical need for follow up treatment.