Distal Common Bile Duct Obstruction Research Articles

Percutaneous Transhepatic Sono-guided Trocar Gallbladder Drainage in Emergency Room Patients

Background Sono-guided drainage of the gallbladder is mainly performed using the Seldinger technique. In this study, we used a trocar technique, which is easier to perform in the emergency room (ER), and evaluated the indications and effectiveness of the procedure. Materials and Methods In the past 3 years, 50 ER patients underwent percutaneous, transhepatic, sono-guided trocar drainage of the gallbladder. We retrospectively reviewed the patients' clinical courses, complications and outcomes. Results The clinical diagnoses of the 50 ER patients included 30 with acute cholecystitis, 10 with distal common bile duct (CBD) obstruction with cholangitis and cholecystitis, seven with gallbladder empyema and three with rupture of gallbladder empyema with liver abscess. Of the 50 patients, 29 received non-surgical treatment, while 21 subsequently underwent elective cholecystectomy. Percutaneous transhepatic sono-guided trocar drainage of the gallbladder was successful in all patients. The overall mortality rate was 10%, but the patients did not die due to the procedure. Four of these patients had complications including severe pain, hemorrhage and catheter dislodgment. Conclusion Most patients who underwent percutaneous transhepatic sono-guided trocar drainage of the gallbladder obtained quick relief of clinical symptoms. It is a safe, fast and inexpensive procedure that does not require fluoroscopy. It is especially well suited for ER patients. Its indications include acute cholecystitis, gallbladder empyema with or without rupture, and distal CBD obstruction with infection.

Pancreatic heterotopia and other uncommon causes of non-malignant biliary obstruction

The vast majority of patients developing obstructive jaundice will have an underlying malignancy. When the etiology of the obstruction cannot be defined prior to operative intervention, identification of a non-malignant process will occur only subsequent to a major operation. The clinical course of a patient with complete distal common bile duct obstruction as the result of pancreatic heterotopia is discussed. This uncommon diagnosis prompted a review of the literature on this subject enabling this detailed discussion inclusive of the embryology, prevalence and clinical presentations of this entity. Our review further identified a varied group of other non-malignant causes of biliary obstruction that may be mistakenly interpreted to represent biliary or pancreatic malignancy.

Biliary stenting versus bypass surgery for the palliationof malignant distal bile duct obstruction: A meta-analysis

The objective of this analysis is to compare endoscopic stenting with surgical bypass in patients with unresectable, malignant, distal common bile duct obstruction using the technique of metes-analysis. The inclusion criteria for the studies were randomized patient assignment, publication in the English language, 20 or more patients per group, all patients followed up until death, and follow-up and complications reported in an equivalent way for both treatment arms. Data extraction was performed independently by 2 of the authors. The number of treatment failures, serious complications, requirement for additional treatment sessions, and 30-day mortality were extracted. Three existing trials met the inclusion criteria, all of which compared surgery with the use of plastic stents. There were no studies identified that used metallic expandable stents. For the rate of treatment failure and serious complications, the odds ratios (ORs) of the 3 trials were heterogeneous, and no summary ORs were calculated. More treatment sessions were required after stent placement than after surgery, and a common OR was estimated to be 7.23 (95% confidence interval [CI], 3.73 to 13.98). Thirty-day mortality was not significantly different (OR = 0.522; 95% CI, 0.263 to 1.036). Although surgical bypass required fewer additional treatment sessions, existing data do not allow a definitive conclusion on which treatment is preferable. A larger randomized controlled trial using newer metallic stents and proper quality-of-life instruments is required.

Normal and Diseased Gallbladder Biles:Spectral Analysis by in vivo Proton MR Spectroscopy

Purpose: To investigate the in vivo proton MR spectra of the bile of human gallbladder in its normal and diseased states and to compare the findings between the two groups. Materials and Methods: In vivo proton MRS was performed in 88 subjects comprising 33 healthy volunteers, 41 patients with gallstone, and 14 with distal common bile duct obstruction. For this, a clinical 1.5T system with a body coil and STEAM (STimulated Echo-Acquisition Mode) was used. We analyzed the MR spectra of normal and diseased gallbladder biles and tried to categorized the findings according to the significant peaks occuring within consistent ranges of chemical shift. We also compared the spectral patterns between normal and dis-eased bile. Results: Proton MRS showed four significant major peaks in normal and diseased human bile: peak 1 at 0.8 - 1.4 ppm, peak 2 at 3.2 -3.4 ppm, peak 3 at 3.9 -4.1 ppm, and peak 4 at 5.2 -5.4 ppm. In each group, peak 1 was most frequent(healthy volunteers, 91%, patients with gallstone, 100%, patients with distal common bile duct obstruction, 93%), but as compared with normal bile (peak 2, 36%, peak 3, 33%), in patients with gall-stone, peak 3 was more frequently seen (46%), and in those with distal common bile duct obstruction, peaks 2 (64%) and 3 (64 pattern II: peaks 1 and 2; pattern III: peaks 1 and 3; pattern IV: peaks 1, 2, and 3; pattern V: peaks 1 and 4; pattern VI: peak 3. In normal bile, the common MR spectral patterns were I (36%), II (27%), III, IV, VI, and V, in decreasing order of frequency. In patients with gallstone, however pattern I (44%) and pattern IV (34%) predominated, while in those with distal common bile duct obstruction, pattern IV (57%) Conclusion: The spectra of normal and diseased gallbladder bile obtained by in vivo proton MR spectroscopy varied, with some differences in spectral patterns between both groups.

Antenatal Diagnosis of Choledochal Cyst

We report five infants in whom antenatal diagnosis of choledochal cyst was established by ultrasonography, and we review the seven previously reported cases. All but one infant had cystic dilatation of the common bile duct (type 1 cysts), and all infants were diagnosed during the second or third trimester. Eight of 12 infants (67%) developed jaundice in the first few days of life, but only 25% had a palpable abdominal mass. Seven of nine infants (78%) demonstrated complete obstruction of the distal common bile duct on intraoperative cholangiography. Liver histology was available for six patients. Five of six had cirrhosis or fibrosis with bile duct proliferation. All of the infants with fibrosis or cirrhosis had distal common bile duct obstruction. Despite liver biopsy findings of extensive fibrosis plus ascites with failure to thrive in one of our patients, all five patients demonstrated clinical and biochemical improvement following surgical excision and porto- or choledochoenterostomy. All were free of symptoms by 6 months of age. Congenital choledochal cyst should be considered in the differential diagnosis of any sonolucent abdominal mass of the fetus. Neonates with distal common bile duct obstruction and fibrosis in association with presumed choledochal cyst should have prompt surgical exploration, intraoperative cholangiography, and close postoperative follow-up. The long-term outcome with prompt surgical correction is excellent.

Antenatal Diagnosis of Choledochal Cyst

SummaryWe report five infants in whom antenatal diagnosis of choledochal cyst was established by ultrasonography, and we review the seven previously reported cases. All but one infant had cystic dilatation of the common bile duct (type 1 cysts), and all infants were diagnosed during the second or third trimester. Eight of 12 infants (67%) developed jaundice in the first few days of life, but only 25% had a palpable abdominal mass. Seven of nine infants (78%) demonstrated complete obstruction of the distal common bile duct on intraoperative cholangiography. Liver histology was available for six patients. Five of six had cirrhosis or fibrosis with bile duct proliferation. All of the infants with fibrosis or cirrhosis had distal common bile duct obstruction. Despite liver biopsy findings of extensive fibrosis plus ascites with failure to thrive in one of our patients, all five patients demonstrated clinical and biochemical improvement following surgical excision and porto‐ or choledochoenterostomy. All were free of symptoms by 6 months of age. Congenital choledochal cyst should be considered in the differential diagnosis of any sonolucent abdominal mass of the fetus. Neonates with distal common bile duct obstruction and fibrosis in association with presumed choledochal cyst should have prompt surgical exploration, intraoperative cholangiography, and close postoperative follow‐up. The long‐term outcome with prompt surgical correction is excellent.

Gallbladder ejection fraction and its relationship to sphincter of Oddi dysfunction.

Theoretically, relative distal common bile duct obstruction due to sphincter of Oddi dysfunction may be a cause of poor gallbladder evacuation observed on quantitative cholescintigraphy. In this study, the relationship of sphincter of Oddi dysfunction to the gallbladder ejection fraction by quantitative cholescintigraphy was explored. Eighty-one patients with biliary-type pain and otherwise normal evaluations underwent quantitative cholescintigraphy, sphincter of Oddi manometry, and ERCP. Abnormalities of stimulated quantitative cholescintigraphy and/or sphincter of Oddi manometry were present in 70% of this study group. Manometric evidence of sphincter dysfunction was present in patients with similar frequency irrespective of the degree of gallbladder evacuation. In conclusion, abnormalities of quantitative cholescintigraphy and sphincter manometry appear to be independent factors, although frequent findings in this patient population.

Endoscopic Biliary Drainage of Postoperative Biliary Fistulae and Leak

Five consecutive patients with postoperative biliary fistulae or leak were diagnosed and treated successfully by endoscopic intervention. The development of the fistulae were related to distal common bile duct obstruction by stones in four patients and in one patient by hydatid daughter cysts. Endoscopic sphincterotomy with stone or cyst extractions achieved decompression of the biliary system and initiated closure of the fistulae. In two patients, nasobiliary tube was used and endoscopic endoprosthesis was needed to close the fistula in another patient. In such cases, endoscopic management seems to be superior to surgical re-intervention for repair of fistulae or leak.

Digging for a diagnosis

A 45-year-old man presented with a 1 week history of progressive painless jaundice. An ultrasound examination at the referring hospital indicated distal common bile duct (CBD) obstruction. Six years previously he had noticed swelling around both mandibular angles and an orthopantomograph had shown two rounded radio-opaque masses in these areas (Fig. 1). One year later, the patient had a colectomy with an ileo-rectal anastomosis.

The Ultrasonographic “Common Channel” Sign

We describe an ultrasonographic "common channel" sign as the characteristic sonographic feature of malignant distal common bile duct (CBD) obstruction. Of 24 patients with obstructive jaundice due to distal CBD obstruction (pancreatic carcinoma 8, periampullary cancer 5, choledocholethiasis 10, CBD stricture due to pancreatitis 1) in whom the final diagnosis was proven at laparotomy, ultrasonography revealed 11 patients to have a thin-walled distended gallbladder continuous with a dilated CBD, which was termed the "common channel" sign. In all 11 patients, the cause of obstruction of the lower end of CBD proved to be malignant (pancreatic carcinoma 6, periampullary 5). In contrast, only 2 of the other 13 patients with obstructive jaundice with distal CBD obstruction, but without the "common channel" sign, had a malignant lesion at the lower end of CBD. The positive and the negative predictive values of the common channel sign were 100% and 85%, respectively. Thus, the ultrasonographic common channel sign is a reliable and characteristic feature of distal CBD obstruction due to malignant pathology.

The transhepatic approach to a failed endoscopic sphincterotomy

Endoscopic sphincterotomy, first described in 1974/,2 is now an accepted procedure for the management of retained or recurrent bile duct stones and other miscellaneous causes of distal common bile duct obstruction. Selective cannulation of the common bile duct is necessary for safe sphincterotomy but cannot always be achieved because of papillary stenosis, duodenal diverticula, previous gastric surgery, or anatomical anomalies. This article describes a technique for using a percutaneous transhepatic biliary drainage (PTBD) catheter to facilitate introduction of the endoscopic sphincterotome into the common bile duct.

Clinical Spectrum and Diagnostic Strategies in Non-Calculous Lower Bile Duct Obstruction

The clinical spectrum and the diagnostic strategies in 99 patients with non-calculous distal common bile duct (CBD) obstruction seen over a period of 5 years have been studied. A benign stricture was found in 26 patients, 15 had a distal cholangiocarcinoma, 11 a periampullary tumour, 45 cancer of the pancreatic head and 2 duodenal cancer. The presenting symptoms were non-specific and allowed no differentiation between the groups. Similarly, biochemical and radiological findings did not reliably distinguish benign from malignant causes of obstruction. Misdiagnosis was common except in the pancreatic tumour group, with previous surgery undertaken in 38% of the patients. A high resectability rate was found for CBD tumours (80%) and periampullary tumours (73%). High morbidity and mortality rates were found for both resective and palliative surgery. The non-specific symptom pattern in these patients and the high frequency of misdiagnosis points to the need for a thorough pre- and intra-operative diagnostic strategy. An operation should not be performed if the surgeon is not prepared to proceed with elaborate and extended surgery.

The risk of hepatic artery embolization in the presence of obstructive jaundice.

Rhesus and cynomolgus monkeys were used as experimental subjects to determine the extend to which the presence of biliary obstruction increases the risk of hepatic necrosis following hepatic artery embolization. It was found that peripheral hepatic artery embolization without biliary obstruction resulted in acute hepatic swelling and dysfunction and chronic focal infarction with bile cyst formation. However, massive hepatic necrosis and bile lakes were not seen. Distal common bile duct obstruction unaccompanied by arterial occlusion did not seriously damage the liver, although it was found that distal common duct obstruction in monkeys is not strictly comparable to distal common duct obstruction in humans. When peripheral hepatic artery embolization was performed following ligation of the right or left hepatic ducts at the point of their emergence from the porta hepatis, total infarction of the obstructed segment occurred and a massive bile lake formed. The pathophysiologic explanation is probably the decreased portal venous inflow that accompanies biliary obstruction; hepatic artery inflow reciprocally increases and the liver become critically dependent upon an intact arterial system. Clinical evidence suggests that a liver with a recently decompressed biliary tree may also be more susceptible to infarction and abscess formation following hepatic artery ligation or embolization.

Distal common bile duct obstruction: an experimental study in monkeys.

Biliary obstruction was accomplished by surgically occluding the distal common bile duct in seven rhesus monkeys. Ultrasound scanning at 24-hour intervals showed that dilation of the common bile duct and gallbladder occurred before elevation of bilirubin or development of jaundice. The bile ducts expanded centrifugally from the obstructing point, with dilation of the intrahepatic ducts occurring several days after the onset of obstruction. After surgical release of the obstruction, the biliary ducts contracted centripetally, with the common bile duct requiring 30-50 days to return to normal size.

Infusion hepatotomography for evaluation of obstructive jaundice.

Total body opacification with high doses of a urographic contrast agent demonstrated dilated intrahepatic biliary ducts as branching or rounded lucencies in all of 18 patients with obstructive jaundice. Dilated extrahepatic ducts were seen as tubular lucencies in 11 of 16 patients with distal common bile duct obstruction. In seven patients with nonobstructive jaundice and in a control group of 25, the biliary ducts were either normal or not seen. Gallbladder size was also evaluated. The site of obstruction could be predicted by the size of the gallbladder and visualization of the biliary ducts.