Distal Common Bile Duct Stone Research Articles

Role of Preoperative MRCP in the Management of Biliary Pancreatitis: A Retrospective Study from Saudi Arabia

Background: Gallstones are the leading cause of acute pancreatitis worldwide. Acute biliary pancreatitis occurs when distal common bile duct stones obstruct the ampulla. This can result in severe consequences for some patients, including significant fluid loss, metabolic imbalances, hypotension, and sepsis. Definitive management strategies for choledocholithiasis include laparoscopic cholecystectomy and/or endoscopic retrograde pancreatography. Magnetic resonance cholangiopancreatography (MRCP) has been increasingly used to evaluate bile duct pathology, leading to more frequent pre-operative biliary duct evaluations for patients with acute gallstone pancreatitis. Despite its widespread use, there have been conflicting reports in the literature regarding its effectiveness and impact on hospital stay duration and healthcare-associated costs. Aim: The aim of this study was to compare the impact of performing MRCP in biliary pancreatitis and its utility, measure its cost-effectiveness, and assess the sensitivity and specificity of different laboratory and radiological investigations in diagnosing impacted biliary stones. Methods: This study followed a retrospective design and analyzed, the records of all patients diagnosed with acute biliary pancreatitis during the study period (2015-2019). Data regarding the following variables were obtained and analyzed from patients’ records: age, comorbidities, and previous medications of the patients; BISAP pancreatitis severity score; serum amylase, at the time of admission; serial recordings for biomarkers and liver function test results (for Day, 1, 3, and 6); ultrasonography results; computed tomography results; MRCP and ERCP results; postoperative complications; length of hospital stay in days; and the time waiting for surgery in days. Results: 133 participants were found in the hospital admission registry and included in this analysis, with an average age of 51.73 years. At the time of admission, the average serum amylase level was 1310 units/liter. Regarding the length of hospital stay, 8.9 days was the average among the patients, with a maximum length of stay of 48 days. Our analysis revealed that MRCP has a sensitivity of 77% and a specificity of 64% for detecting CBD stones. Patients who had MRCP stayed longer at the hospital with an average of 9.21 days, although the difference was not statistically significant (p-value: 0.570), compared with International Journal of Surgery & Surgical Techniques 2 Shaher A, et al. Role of Preoperative MRCP in the Management of Biliary Pancreatitis: A Retrospective Study from Saudi Arabia. Int J Surg Surgical Tech 2023, 7(2): 000196. Copyright© Shaher A, et al. an average of 6.15 among patients who did not have MRCP. As for the days to surgery, the average time until surgery was 3.79 (standard deviation 3.73), with a maximum of 16 days until surgery. Patients who had MRCP had to wait for a longer period of time until surgery than their counterparts who waited for less than a day for their surgery (p-value: < 0.001). Conclusion: Our results revealed that patients who underwent MRCP preoperatively had a longer hospital stay and significantly waited longer for surgery than their counterparts. However, more multi-centered, large studies are needed to further support our findings.

S372 Cystic Artery Pseudoaneurysm: A Rare Case of Upper Gastrointestinal Bleeding

Introduction: Cystic artery pseudoaneurysm (CAP) is a rare complication of acute cholecystitis and cholecystectomy. We present an unusual case of upper GI bleed due to CAP. Case Description/Methods: An elderly female presented with one month history of lethargy and unintentional weight loss. Clinical exam was unremarkable apart from pallor. Blood tests revealed severe iron deficiency anaemia and bland cholestasis. CT scan showed a common bile duct (CBD) mass and a gallbladder (GB) neck lesion with prominent regional lymph nodes, which was worrying for biliary malignancy. MRI scan showed a 3cm CBD stone with acute emphysematous cholecystitis and possible CAP at the GB neck. An urgent OGD and ERCP was done on the same day as she developed hematemesis and cholangitis. On endoscopy, there was active bleeding from possible enteric fistula at first part of duodenum (D1), this was treated with metal clips. During ERCP, haemobilia was noted on CBD cannulation. On cholangiogram, the endoclips were adjacent to distal CBD stone. A plastic stent was inserted into the CBD and she was referred to the surgeons. Cholecystectomy and CBD exploration was performed for definitive treatment. Intra-operatively, there was active bleeding into the GB from CAP. D1 was thinned out with adhesions to the GB. There was stale blood in the bile duct but no biliary-enteric fistula seen. CAP was sutured, adhesiolysis, subtotal cholecystectomy, omental patch repair of D1 and CBD stone was retrieved. Repeat OGD and ERCP with CBD stent removal done 2 months later showed healed D1 mucosa. Discussion: The clinical features of CAP include right upper quadrant pain, upper GI bleed due to haemobilia and abnormal liver enzymes. It is diagnosed on arterial phase of CT scan, angiography, MRI or during surgery. It is treated with surgery or angioembolization. This is a challenging case with delayed diagnosis of CAP as she lacks the typical presentation of CAP. A plain contrasted CT without arterial phase was done initially, which have mistaken the CAP as soft tissue lesion in GB. Endoscopic findings raises possibility of choledocho-duodenal fistula; this was excluded during surgery. The final diagnosis is acute calculous cholecystitis complicated by CAP with direct pressure on D1 leading to upper GI bleed. To our knowledge, this is the first case of CAP with such entity. In conclusion, CAP should be considered in patients with symptomatic gallstone disease and upper GI bleed in order to select appropriate imaging modality and guide therapy. Watch the video at https://tinyurl.com/ACGAbstractS372

EP.FRI.199 Impacted common bile duct stone managed by hepaticoduodenostomy

Abstract The management strategy of common bile duct stone will depend on personal experience, equipment availability, time and the availability of other departmental expertise. For a distally impacted common bile duct (CBD) stone in a low resource setting, an open approach will entail either leaving the stone where it is and carry out a choledochoduodenostomy, or removing the stone through a transduodenal sphincteroplasty. The latter has a significant risk of causing an acute pancreatitis. A case report of a hepaticoduodenostomy performed on a 40-year-old black African man for a retained, impacted distal CBD stone in a low resource setting with a good outcome is presented. The impacted CBD stone had complicated an open cholecystectomy for acute cholecystitis by causing the dehiscence of the cystic duct stump as a result of distal biliary obstruction. A bypass procedure such as a hepaticoduodenostomy may be an alternative to the traditional choledochoduodenostomy in the management of the retained, impacted distal CBD stone especially in the presence of sepsis. A wide side- to-side hepaticoduodenostomy (>3cm d) is a safe and definitive procedure for the decompression of lower CBD obstruction and has good long-term results with infrequent complications including reflux cholangitis, hepatic abscess, stone recurrence, pancreatitis and the ‘sump’ syndrome. This case demonstrates that a hepaticoduodenostomy is safe and effective in rescuing the adverse sequelae of an impacted distal CBD stone in a low resource setting.

Laparoscopic assisted trans-gastric endoscopic retrograde cholangiopancreatography (LA-ERCP) for postoperative bile leakage: A case report

Laparoscopic assisted trans-gastric endoscopic retrograde cholangiopancreatography (LA-ERCP) is a safe and effective technique for cholelithiasis. We report a successful treatment case through LA-ERCP in patient with bile leakage after laparoscopic common bile duct (CBD) exploration because of the patient's limited degree of mouth opening due to trismus and limb stiffness. Here we present a case of a 51-year-old male patient with trismus, limb stiffness after suffering from poliomyelitis. The patient showed acute calculous cholecystitis and acute cholangitis with distal CBD stones. He was unable to receive trans-oral ERCP or percutaneous trans-hepatic biliary drainage (PTBD) because of the limited degree of mouth opening due to trismus and stiffness in his both arm across his chest. So we performed laparoscopic cholecystectomy and removed distal CBD stones through CBD exploration. On the fourth day after the operation, bile leakage was observed. Because he was unable to receive trans-oral ERCP or PTBD, we decided to perform LA-ERCP. We performed LA-ERCP and successfully inserted endoscopic retrograde bile duct drainage (ERBD) into the common bile duct. During the procedure, the endoscope was introduced through a gastrostomy, obviating the need for an intragastric trocar. The patient underwent ERBD. The patient was discharged on 11 postoperative day without any complications. For the patients in whom trans-oral and trans-hepatic route are unavailable, LA-ERCP represents an effective approach for the management of biliary complications after laparoscopic cholecystectomy and offers a novel solution.

The Role of Endoscopic Retrograde Cholangiopancreatography in the Management of Biliary Complication Post-Laparoscopic Cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy considers a golden surgery for gallbladder removal nowadays, and it carries some complications like biliary injuries, which can manage successfully by endoscopic retrograde cholangiopancreatography. AIM: To estimate the role of endoscopic management of bile duct injury (BDI) following laparoscopic cholecystectomy. PATIENT AND METHODS: A prospective study conducted at Al-Sader Medical City, Najaf City, Iraq, during the period between September 2018 and December 2020, included 44 patients complicated by the biliary injury resulting in a persistent biliary leak and/or jaundice after laparoscopic cholecystectomy and evaluated by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Findings revealed that 25% of cases had complete BDI, only one managed by plastic stent placement, the other 10 referred for open surgical constructions, 61% had partial injury associated with the biliary leak, all managed by sphincterotomy and plastic stent placement through ERCP, almost 7% had a partial clipping of bile duct all managed with sphincterotomy, balloon dilatation/stone extraction, and plastic stent placement, 5% had slipped clips of cystic duct stump, are managed with sphincterotomy and plastic stent placement. Moreover, only one patient, 2%, had distal common bile duct stone with bile leak, managed by sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic cholecystectomy, a gold standard therapeutic option for symptomatic cholecystolithiasis, is associated with an increased risk of biliary injury due to many factors. ERCP is a safe means of diagnosing the cause of bile leakage after laparoscopic cholecystectomy. It also offers definitive treatment in most cases by endoscopic sphincterotomy and plastic stent placement.

PANCREATITIS-INDUCED ACUTE ST SEGMENT ELEVATION AND REGIONAL WALL MOTION ABNORMALITY

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute myocardial infarction (AMI) mimics causing ST segment elevation present a diagnostic conundrum for physicians. Recognition of uncommon causes of AMI mimics is essential in reducing patient exposure to unnecessary intervention. CASE PRESENTATION: A 49-year-old male with a past medical history of hypertension presented to the emergency with a chief complaint of severe epigastric pain radiating to his back. He had undergone ERCP earlier in the day for removal of a common bile duct (CBD) stone. Severe epigastric tenderness was observed on physical exam. Laboratory evaluation revealed WBC count of 25700/mcL, Hb 19.8 g/L, BUN 25 mg/dL, creatinine 1.3 mg/dL, alkaline phosphatase 188 IU/L, AST 42 IU/L, ALT 89 IU/L, total bilirubin 1.4 mg/dL, amylase 1059 IU/ L, lipase 21,417 units/L and troponin < 0.015 ng/mL. CT scan of the abdomen revealed an enlarged pancreas with surrounding fat stranding and the presence of a distal CBD stone. EKG was unremarkable (figure 1). The following day, the patient developed tachycardia and reported recurrent epigastric pain. He denied chest pain. EKG evidenced sinus tachycardia, 2-3mm convex ST segment elevation in inferior leads, 1-2mm ST depression in the anterolateral leads was also observed (figure 2). Serial troponin I levels were within the undetectable range. Repeat EKG after 3 hours showed tachycardia with no ST segment elevation (figure 3). Echocardiography revealed a small area of dyskinesia in the inferoseptal wall of the left ventricle. Patient was managed without percutaneous coronary intervention (PCI), thrombolysis or anticoagulation. Patient’s hospital stay was complicated by pancreatic necrosis, abscess, pseudocyst formation, and sepsis. He was discharged on day 19 after recovery. DISCUSSION: The most common EKG changes in pancreatitis are secondary to metabolic derangements such as hypocalcemia, hyponatremia, hypokalemia, hypomagnesemia, and insulin-induced hypoglycemia. QT prolongation, ST depression, U waves, and low amplitude T wave changes are frequently seen. On the other hand, ST elevation is rarely seen. Proposed mechanisms for ST elevation and wall motion abnormality include the cytotoxic effect of proteolytic enzymes on cardiac myocytes, a cardiobiliary reflex resulting in increased vagal tone, coronary vasospasm, exacerbation of underlying coronary artery disease, or coronary thrombus formation from increased platelet adhesiveness and/or pancreatic enzyme induced coagulopathy [1,2,3]. Takotsubo stress cardiomyopathy has been linked to pancreatitis in several reports. Hypothesized pathomechanisms for this transient myocardial dysfunction include catecholamine excess and sympathetic stimulation [2]. CONCLUSIONS: Acute pancreatitis may mimic EKG and echocardiography findings of AMI. In selected cases, knowing this can help avoid unnecessary PCI, thrombolysis or anticoagulation which may lead to serious hemorrhagic complications. Reference #1: Coppola G, Carità P, Corrado E, Borrelli A, Rotolo A, Guglielmo M, et al. ST segment elevations: Always a marker of acute myocardial infarction? Indian Heart Journal. 2013 Jul;65(4):412–23. Reference #2: Yu ES, Lange JJ, Broor A, Kutty K. Acute Pancreatitis Masquerading as Inferior Wall Myocardial Infarction: A Review. Case Rep Gastroenterol. 2019 Aug;13(2):321–35. Reference #3: Ro TK, Lang RM, Ward RP. Acute pancreatitis mimicking myocardial infarction: evaluation with myocardial contrast echocardiography. Journal of the American Society of Echocardiography. 2004 Apr;17(4):387–90. DISCLOSURES: No relevant relationships by Maryam Moghareh, source=Web Response No relevant relationships by Prashank Neupane, source=Web Response No relevant relationships by Zed Seedat, source=Web Response No relevant relationships by Touqir Zahra, source=Web Response

Post Endoscopic Retrograde Cholangiopancrea-Togram (ERCP) Perforation Managed Successfully Conservatively: A Case Report

Introduction: We aim to report an uncommon case of post ERCP perforation that effectively managed conservatively in non-hepatobiliary surgery centre. Case report: A 46-year-old man diagnosed to have obstructive jaundice secondary to distal common bile duct (CBD) stone. He underwent ERCP at a private centre, sphincterotomy was performed, but, the operator had failed to insert the stent and complicated with post ERCP perforation evidenced by contrast extravasation beyond 1/3rd of the CBD and referred to our centre. Patient was subjected for re ERCP. There were difficulties in cannulating the CBD and stent was inserted. Cholangiogram revealed contrast leak around the pancreatic duct and bifurcation of hepatic duct. There was no evidence of CBD stone. Computed Tomography (CT) of the abdomen revealed extensive subcutaneous emphysema on the right side of the abdomen to right inguinal region, extensive retroperitoneal free air and pneumoperitoneum, but there were no free fluid or contrast extravasation. The patient subjected for non-operative management (NOM) for the complication and kept fasting with total parenteral nutrition and intravenous antibiotic. He recovered well with the opted management. Patient was programmed with Gastrograffin study after 10 days that showed no evidence of contrast leak to suggest free bowel injury. He was allowed orally after that and was discharged well after 15 days with stent in situ. During follow up, he was well, and the stent removed after 3 months. Patient planned for laparoscopic cholecystectomy and on table cholangiogram. Conclusion: Post ERCP perforation is uncommon but lethal. Early recognition of the complication is crucial hence appropriate management can be arranged to avoid death. To date, surgery is not the only choice available to manage this complication.

2605 Distal Intestinal Obstruction Syndrome Resulting in Gastric Perforation in a Patient With Cystic Fibrosis

INTRODUCTION: Distal Intestinal Obstruction Syndrome (DIOS) is a unique entity that occurs in patients with cystic fibrosis. DIOS results from the accumulation of mucous and undigested food contents in the small intestine due to decreased luminal water secretion which ultimately leads a proximal obstruction that can cause perforation, shock, and death if not treated. DIOS has an incidence rate of 35 in 1000 adults with cystic fibrosis. Here, we present a unique of DIOS which resulted in gastric perforation. CASE DESCRIPTION/METHODS: A 43-year-old male with cystic fibrosis and double lung transplant was admitted with cramping abdominal pain and decreased oral intake. On admission, he was noted to have abnormal liver function tests with total bilirubin of 9.6 and alkaline phosphatase of 888. A CT scan showed dilation of his common bile duct to 1 cm with ultrasound demonstrating distal common bile duct stones. He underwent endoscopic retrograde cholangiopancreatography with stone extraction and improvement in abdominal symptoms. He received significant narcotics for pain, and his hospital course was then complicated by constipation, worsening abdominal pain, and emesis. Gastroenterology was consulted and recommended a nasogastric tube (NG) and hyperosmolar enema to treat DIOS. An NG tube was unable to be passed and the patient’s abdominal pain suddenly worsened. An upright x-ray was obtained and demonstrated lucency over the right crus with non-contrast CT confirming pneumoperitoneum suggestive of a small bowel perforation. He was emergently taken to the operating room where he was found to have a 2 cm gastric perforation. A gastric wedge resection and omental patch was performed. The patient’s post-operative course involved total parenteral nutrition, scheduled enemas, and strict NPO status. An upper GI series showed no extravasation of contrast. The patient was extubated, started on oral intake, and eventually discharged on an aggressive bowel regimen. DISCUSSION: This case highlights a rare complication of DIOS. Typically, patient with DIOS are at risk for intestinal perforation; however, this patient developed a gastric perforation possibly from prior area of structural weakness. This case also highlights the importance of an aggressive bowel regimen in patients with cystic fibrosis to prevent DIOS. Once DIOS is identified, hyperosmolar enemas such as hypaque enemas and oral laxatives containing polyethylene glycol should be used for aggressive treatment to stymie such complications.

1376 Pseudoaneurysm of the Cystic Artery: An Unusual Case of Hemobilia in a Teenage Patient

INTRODUCTION: Pseudoaneurysm of the cystic artery is a rare cause of hemobilia and often derives from the inflammatory changes in cholecystitis. Knowledge regarding this topic is limited with rare occurrence reported in the literature. This may be the first reported case of a cystic artery pseudoaneurysm causing biliary obstruction in a pediatric patient. This case emphasizes the importance of considering hemobilia whenever gastrointestinal bleeding is associated with cholestatic liver injury as well as including cystic artery aneurysm in the differential diagnosis of hemobilia. CASE DESCRIPTION/METHODS: A 16-year-old obese male scheduled for elective cholecystectomy for symptomatic cholelithiasis was admitted for worsening abdominal pain associated with nausea and vomiting. After admission, patient remained afebrile with resolving symptoms, but rising cholestatic markers. MRCP showed Common Bile Duct (CBD) dilation to 1 cm but without CBD stones. EUS was performed to evaluate for choledocholithiasis but was limited by the unexpected finding of fresh blood in the duodenum. CBD dilation to 8 mm was seen but was without evidence of CBD stones. Cholestatic injury worsened, prompting ERCP as distal CBD stones were still the leading concern. Upon examination prior to cannulation, passage of blood and blood clots was seen from the native ampulla. Cholangiogram showed multiple filling defects within the CBD suggestive of blood clots, sphincterotomy was performed and multiple sweeps with the balloon catheter removed only blood clots with no stones seen. CT angiography was performed and found a focal arterial density collection in the posteromedial gallbladder wall, most likely due to a pseudoaneurysm of the cystic artery. Interventional Radiology performed coil embolization of the cystic artery prior to cholecystectomy. Laparoscopic cholecystectomy was converted to open laparotomy after the discovery of extensive pericholecystic adhesions to the gallbladder as well as a cholecystocolonic fistula. The fistula was repaired and the gallbladder was removed with ligation of the cystic artery just distal to the coils. Symptoms resolved and the patient's laboratory values normalized. DISCUSSION: A rare case of cholestatic liver injury and hemobilia secondary to cystic artery pseudoaneurysm in a pediatric patient is reported. As demonstrated in this report, immediate angiography and embolization of the involved artery followed by cholecystectomy may be the optimal treatment regardless of patient age.

2630 Late Presentation of Caroli’s Syndrome: A Rare Cause of Cholangiocarcinoma

INTRODUCTION: Caroli’s syndrome (type 2) is a rare, complex form of Caroli’s disease (type 1) with an estimated incidence of 1/1,000,000. The syndrome manifests as saccular dilatations of the intra-hepatic biliary ducts and is associated with fibrosis and portal hypertension, distinguishing it from the disease form. Additionally, it predisposes patients to regionalized malignancy. Generally this presents before the age of 40. Intriguing however in our case, was the late presentation of the disease. The aim of this case report is to educate clinicians as to an obscure presentation of this rare disease, in an attempt to prevent cirrhosis, as well as subsequently increase the early detection of cancer. CASE DESCRIPTION/METHODS: We present a 78-year-old Asian female with a history of hypertension and cholelithiasis whom presented to the hospital with abdominal pain, jaundice, and fever. Magnetic resonance cholangiopancreatography (MRCP) revealed saccular intra-hepatic ductal dilations with a distal common bile duct (CBD) stone (Figure 1). Subsequent endoscopic retrograde cholangiopancreatography (ERCP) with biopsy, and balloon sweeping, removed the stone. Upon histologic examination of the targeted liver biopsy severe fibrosis was observed, confirming the diagnosis of Caroli’s syndrome (Figure 2). Two years later the patient returned to the office with new onset weight loss and nausea. CA19-9 was elevated at 1191. Magnetic resonance imaging (MRI) of the abdomen showed biliary duct dilation and enlarged lymph nodes (Figure 3). Endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) of the celiac lymph nodes was subsequently performed. Upon immunohistochemistry, the pathology showed tumor glands positive for CK7 and CDX2--consistent with metastatic adenocarcinoma of pancreaticobiliary origin. DISCUSSION: Caroli’s syndrome is a rare, autosomal recessive disorder that typically manifests in a patients early twenties. Interestingly, our patient did not develop any symptoms until the age of 78. Distinguishing Caroli’s syndrome from recurrent pyogenic cholangitis is key and can be done in the setting of saccular dilatations on imaging as in our case. If the disease is diagnosed prior to the development of cirrhosis or cancer, patients may benefit from liver transplant. Individuals with Caroli’s disease are at a higher risk for developing cholangiocarcinoma. Prompt diagnosis of Caroli’s syndrome and awareness of the risk for cancer is vital, as the potential for malignancy and metastasis is significant.

A rare case of spontaneous common bile duct perforation

Spontaneous perforation of the common bile duct (CBD) in adults is an extremely rare complication of gallstones. It is challenging to establish the diagnosis pre-operatively however with increasing utility of computer tomography, there may be subtle features visualized. We describe a case of a 35 year old Indian male who presented with an acute abdomen and was found to have biliary peritonitis secondary to a spontaneous CBD perforation. Mr JJ presented with sudden onset of abdominal pain associated with vomiting and diarrhea. He had generalized abdominal peritonitis. Initial erect chest x-ray was unremarkable for free air under the diaphragm, hence a CT was performed which revealed moderate amounts of free fluid around the 2nd part of the duodenum extending along the anterior para-renal space into the pelvis, with a 4mm distal CBD stone resulting in mild upstream dilatation. The gallbladder was decompressed and the CBD wall was not well visualized in the mid-portion, raising the possibility of perforation. An exploratory laparotomy revealed generalized biliary peritonitis secondary to a 2 cm CBD perforation just distal to the cystic duct junction. Choledochoscopy confirmed the small 4mm distal CBD stone which was advanced successfully through the ampulla into the duodenum. He underwent abdominal lavage, cholecystectomy, choledochectomy and a roux-en-Y hepatico-jejunostomy reconstruction. His recovery was uneventful. Histology confirmed focal transmural necrosis of the bile duct with fibrosis and micro-abscess formation. Clinicians should be aware that whilst spontaneous extrahepatic bile duct perforations are rare, it is important as timely diagnosis can be life-saving.

Iatrogenic Portal Vein Injury During Biliary Stent Placement

Complications of endoscopic retrograde cholangiopancreatography (ERCP) beyond pancreatitis are rare. Reports on management of rare complications are also scarce. One such complication is internal biliary fistulas. Our case examines an incident of an iatrogenic portobiliary fistula (PBF) formation post biliary stent placement and discusses management. A 39 year-old female with congenital dwarfism presented with abdominal pain, distension and bilious vomiting for 2 weeks. The patient was afebrile and hemodynamically stable. On exam, she was without jaundice and in slight distress secondary to pain primarily focused in the right upper quadrant (RUQ) with guarding and rebound. Labs showed transaminitis, bilirubinemia and mild leukocytosis. CT of the abdomen demonstrated intra- and extra-hepatic biliary ductal dilation to the level of the ampulla of Vater and the common bile duct (CBD). Ultrasound of the RUQ demonstrated gallbladder stones with a 4mm wall and pericholecystic fluid. Out of concern for acute cholangitis, fluids and antibiotics were initiated and patient underwent ERCP. During ERCP, deep wire cannulation of the CBD and cholangiogram was performed confirming dilated biliary tree with distal CBD stone. Resistance was felt in passing the sphincterotome through the papillary orifice. A biliary sphincterotomy was performed without obvious complication. A balloon was inserted and sphincterotome removed. There was resistance passing the balloon catheter and sweeping of the stone was unsuccessful. A 7-French 7-cm stent was placed and resistance was met again with passing the stent. Fresh blood was noted upon stent deployment. The proximal stent appeared outside the biliary system on fluoroscopy. The stent was kept in place and emergent laparotomy and CBD exploration was performed. The stent was noted to pass from the CBD into the portal vein. The portal vein and ductal injury was repaired, and a T-tube placed. Intraoperative cholangiogram revealed retrograde filling without leaks. Post-operatively the patient did well without further complications and was discharged. Iatrogenic PBF in this case required surgical intervention as removal endoscopically could have led to exsanguination. As an alternative to surgery, interventional radiology via balloon could tamponade bleeding while the stent is replaced. Our case demonstrates that stent retention can allow for tamponade until further intervention is available, whereas removal could result in exsanguination.

An Unusual Cause of Prolonged Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Jaundice

Elevated liver function tests (LFTs) can be caused by numerous etiologies such as infection, choledocholithiasis, toxins, and chronic disorders. It can also occur after invasive procedures like endoscopic retrograde cholangiopancreatography (ERCP). Here we present the case of a young woman who suffered an unusual complication, prolonged jaundice after ERCP, of which the etiology was initially unclear. A 32-year-old woman with history of cholelithiasis presented with abdominal pain. Her LFTs were elevated, including total bilirubin of 3.8 and direct bilirubin of 2.1. A right upper quadrant ultrasound revealed cholelithiasis and common bile duct (CBD) dilation at 11 mm. ERCP confirmed these findings as well as a distal CBD stone which was removed; a plastic biliary stent was placed. Gastritis was noted and confirmed histologically to be due to H. pylori. She was discharged on pantoprazole, clarithromycin, and amoxicillin. As an outpatient, she underwent laparoscopic cholecystectomy; at this time her total bilirubin was 3.4. At follow-up two weeks later, she complained of continued pruritis and jaundice. She was admitted as her total bilirubin was found to be worsening at 4.1. A second ERCP did not reveal bile leak, stenosis, or stone retention. She was discharged however at one week follow-up she still reported pruritis and jaundice. Extensive laboratory work-up including viral and autoimmune hepatitis were negative. On careful review, it was found that she had been erroneously prescribed four weeks of clarithromycin, instead of the standard two week regimen for H. pylori. The drug was discontinued. At follow-up four weeks later, her pruritis and jaundice had resolved and her LFTs were greatly improved (total bilirubin 1.1). Six months later all liver enzymes were within normal range. In this case, the cause of the patient's jaundice and elevated LFTs was initially unclear. Prolonged jaundice after ERCP and subsequent cholecystectomy is a rare complication. Post-cholecystectomy jaundice could be caused by ischemia, viral hepatitis, bile leak, biliary stricture, or infection. Here, a second ERCP did not reveal any such complications which could have explained her symptoms. The chronology of events and LFT trends favored the cause of liver insult as due to clarithromycin. We posited that this was due to drug-induced liver injury (DILI). Discontinuation of the offending agent, as in our patient, lead to resolution of symptoms and laboratory derangements.FigureFigureFigure

G-Tube Guided Endoscopic Retrograde Cholangiopancreatography; A Lifesaving Procedure

Introduction: Acute cholangitis is a consequence of obstruction and infection of the biliary tract. Endoscopic retrograde cholangiopancreatography (ERCP) is key in the management of choice as acute cholangitis as stone extraction and/or stent insertion establishes biliary drainage and relief of infection. Anatomical variation following Roux-en-Y gastric bypass surgery or patients with esophageal obstructions like in our case are prone to make the early intervention by ERCP a challenge . We describe a case report of septic cholangitis in a patient whom gastrostomy tube (G-tube) access allowed the performance of successful ERCP which was otherwise impossible. Case report: 75-year-old male with multiple comorbidities and esophageal cancer status post G-tube placement for malnutrition who presented with cholangitis. On admission, the patient had fever, nausea and decrease in level of activity. His initial evaluation showed that the patient had a sepsis with a fever of 99.6, leukopenia with WBC of 2.0, elevation in the liver enzymes with alkaline phosphatase of 238, alanine aminotransferase of 48, total bilirubin 1.2 and lactic acid of 3.2. His infectious workup included blood cultures that grew Enterobacter cloacae. His CT scan showed stone in the common bile duct. MRCP demonstrated a 1.3 cm obstructive distal common bile duct stone with extrahepatic and intrahepatic biliary dilatation. ERCP was unsuccessful due to a partially obstructing esophageal mass. After changing to a small pediatric endoscope, the scope was able to be passing the mass and a showed a good visualization of the ampulla but therapeutic intervention was not successful. Patient was brought back for a second attempt using his G-tube. A wire was passed under fluoroscopy adjacent to the G-tube then the G-tube was removed. Then a stent anchoring system was used with 3 anchors being placed. Subsequently, an axios stent (lumen-apposing self-expandable metallic stent) was placed under combined direct vision and fluoro. The stent was then sutured down in order to prevent migration. Following placemen of the stent balloon dilatation was performed inside the stent up to 15 mm in size. Following dilatation over a jag wire the ERCP scope was passed through the stent and used to cannulate the ampulla. A sphincterotomy was performed and the stone was removed with a balloon catheter. Following completion of the stone removal the Axios stent was then removed and a G-tube was replaced and confirmed with contrast for position. The patient tolerated the procedure without any complication, his bilirubin normalized and the patient discharged in stable condition the next day on a total course of 14 days of antibiotics. Conclusion: In cholangitis patient with limited access, G-tube sites provide a useful access value to examine the gastrointestinal track for therapeutic intervention.

ERCP for Septic Cholangitis Through a Peg Tube, a Life-Saving Procedure Using an Alternative Access Route to Approach the Biliary Tree When the Regular ERCP Fails

Acute cholangitis, is a product of bile stasis and infection of the biliary tract. Diagnostic and therapeutic role of the Endoscopic retrograde cholangiopancreatography (ERCP) has a critical role in the management. Anatomical variation following Roux-en-Y gastric bypass or people who had esophageal obstructions tend to make the early intervention by the ERCP a challenge. We report a case of septic cholangitis in a patient whom the ERCP was achived through a peg tube. Case report: 75-year-old male esophageal cancer & gastrostomy tube for malnutrition presented to the local hospital with fevers. Initial evaluation showed feature of sepsis with a fever, leukopenia, elevation in the liver enzymes & total bilirubin 1.2 and lactic acid 3.2. Ct scan showed a stone in the common bile duct & blood cultures showed Enterobacter cloacae. The patient started on ceftriaxone & transferred to our tertiary center for therapeutic intervention. The patient had a MRCP that demonstrates a 1.3 cm obstructive distal common bile duct stone for which the patient underwent an attempt with ERCP that shortly aborted given partially obstructing esophageal mass. After changing to a small pediatric endoscope, the scope was able to be pass the mass but the procedure terminated due to scope malfunction. Another route to access the biliray system was found; the peg tube was removed after an anchoring system was placed. Following the placement of the anchors an Axio stent was placed & a balloon dilitation was performed inside the stent up to 15 mm in size. Following dilitation an ERCP scope was placed and the papilla was accessed and sphincterotomy was made and stone was removed. After the stone removal, the stent was removed and a peg tube was replaced and the patient tolerated the procedure without any complication & discharged on stable condition. Discussion: ERCP is the treatment of choice in establishing biliary drainage in acute cholangitis. In the setting of anatomical variation, the success rate dramatically dropped below 70% when compare it to the traditional ERCP 90-95%. The literature showed that the success rate is higher using surgically created route through the stomach as a mature gastrostomy, trans-gastric or laproscopic- assisted port are all well tolerated. In patient with limited access for the traditional ERCP, alternative routes can allow the gastroenterologist to drain the blockage; such intervention can improve the mortality & morbidty.

Two Cases of Cerebral Air Embolism That Occurred during Esophageal Ballooning and Endoscopic Retrograde Cholangiopancreatography.

Cerebral air embolism is an extremely rare complication of endoscopic procedure and often life threatening. We present two cases of cerebral infarction due to air embolization caused by an endoscopic intervention. The first case occurred during esophageal balloon dilatation for the treatment of a stricture of an anastomosis site in a 59-year-old man and the second case occurred during endoscopic papillary balloon dilatation in a 69-year-old man who had distal common bile duct stones. After the procedure, cardiopulmonary instability and altered mental status were observed in both patients, and cerebral air embolism was diagnosed in both cases. Hyperbaric oxygen therapy was started in the first case, and high FiO2 therapy was applied in the second case. Although this complication is rare, patient outcomes can be improved if physicians are aware of this potential complication, and immediately begin proper management.

Right Posterior Segmental Hepatic Duct: Role of Intraoperative Cholangiogram to Prevent Extrahepatic Biliary Duct Injuries

Extrahepatic bile ducts constitute a significant anatomic site for surgeons when performing hepatobiliary operations from minor procedure such as cholecystectomy to major operation such as hepatectomy. The challenges for surgeon in performing such cases increase when congenital variance of biliary tree occurs which may lead to unintentional bile duct injuries. We reported a case of a lady who presented with obstructive jaundice secondary to huge distal common bile duct stone. The presence of right posterior segmental hepatic duct, which rarely occurs, was discovered during intraoperative cholangiogram before common bile duct exploration. The operation was successful without incidence of biliary duct injury.

Choledochocele containing a stone mistaken as a distal common bile duct stone

A choledochocele is an expanded sac of the duodenal side of the distal common bile duct (CBD), and is categorized as a type III choledochal cyst. Unlike other choledochal cysts, it can be easily overlooked because of its very low prevalence, non-specific clinical symptoms, and lack of distinctive radiological findings. However, a patient having a repeated pancreaticobiliary disorder with an unknown origin, frequent abdominal pain after cholecystectomy, or repeated non-specific gastrointestinal symptoms can be suspected as having a choledochocele, and a more accurate diagnosis can be achieved via endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound. Because it rarely becomes malignant, a choledochocele can be treated via endoscopic sphincterotomy (EST) and surgical treatment. The authors were able to diagnose choledochocele accompanied by a stone in a patient admitted to the authors’ hospital due to cholangitis and pancreatitis. The patient's condition was suspected to have been caused by a distal CBD stone detected via multiple detector computed tomography and ERCP, and was successfully treated via EST.

Intramural gastric abscess from dropped gallstones presenting as a subepithelial lesion (with video)

A 68-year-old man was referred for management of choledocholithiasis. He had a history of intermittent abdominal pain after a difficult laparoscopic cholecystectomy done 4 months previously. Wound dehiscence unfortunately occurred after the surgery, and a cholesterol stone was retrieved from the wound. A CT scan of the abdomen showed 2 distal common bile duct (CBD) stones and an antropyloric collection (A). ERCP was performed to extract the stones. During the procedure a subepithelial bulge was seen in the antrum (B), and EUS revealed it to be a 2.5 × 2.0-cm heterogeneous lesion with poorly defined outer wall echolayers that was largely confined to the submucosa (C).

Percutaneous Transhepatic Release of an Impacted Lithotripter Basket and Its Fractured Traction Wire Using a Goose-Neck Snare: a Case Report

In a patient with a distal common bile duct stone, a fracture of the traction wire of the basket occurring during the performance of mechanical lithotripsy resulted in the impaction of the lithotripter basket with a stone. The impacted lithotripter basket combined with a fracture of the traction wire is a rare complication of endoscopic stone removal. We were able to pull the impacted basket using an Amplatz goose-neck snare inserted via the percutaneous transhepatic route, which resulted in the freeing of the entrapped stone into the dilated supra-ampullary bile duct. The fractured traction wire and basket could be safely removed by pulling the traction wire from the mouth. The present report is the first to describe the safe and effective use of an Amplatz goose-neck snare for the management of a lithotripter basket impacted with a stone and a fractured traction wire.