Distal Common Bile Duct Stricture Research Articles

Use of Removable Covered Expandable Metal Stents (RCEMS) in the Treatment of Benign Distal Common Bile Duct (CBD) Strictures: A Feasibility Study

The endoscopic treatment of benign CBD strictures comprises of sequential plastic stent insertion in progressively increasing numbers and resolves 65-85% of post surgical strictures and 20-40% of strictures due to chronic pancreatitis (CP). We aimed to assess the feasibility of using RCEMS, especially its removability, in the treatment of benign CBD strictures. Methods: First, proof of principle was tested in 3 patients with irresectable pancreatic cancer (CA). Subsequently, 4 patients with CP with a benign distal CBD stricture were included.

Metal vs plastic stents for malignant distal common bile duct stenosis: A prospective, controlled, randomized clinical trial

Metal vs plastic stents for malignant distal common bile duct stenosis: A prospective, controlled, randomized clinical trial

Treatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: comparison of single vs. multiple simultaneous stents

Common bile duct stenosis occurs in up to 30% of patients with chronic pancreatitis. Most such stenoses are found incidentally during ERCP, but others manifest as obstructive jaundice, recurrent cholangitis, secondary biliary cirrhosis, or choledocholithiasis. Operative drainage has been the main treatment despite the potentially high morbidity in patients with chronic pancreatitis. Endoscopic biliary drainage with a single stent has been successful in the short term. The aim of this study was to determine the long-term benefit of a single stent vs. multiple simultaneous stents for treatment of patients with chronic pancreatitis and symptoms because of distal common bile duct stenosis. Twelve consecutive patients with chronic pancreatitis and common bile duct stenosis underwent endoscopic placement of multiple simultaneous stents and were followed prospectively (Group II). Results were compared with a group of 34 patients in whom a single stent was placed before the start of the present study (Group I). All 46 patients (35 men, 11 women; age range 30-71 years) had chronic pancreatitis and common bile duct stenosis, and presented with symptoms indicative of obstruction (abdominal pain, jaundice, elevated biochemical tests of liver function, acute pancreatitis, cholangitis). The 34 patients in Group I had single stent (10F, 7-9 cm) placement, with exchange at 3 to 6 month intervals (1-4 exchanges) over a mean of 21 months. The 12 patients in Group II underwent placement of multiple simultaneous stents at 3-month intervals (single 10F stents added sequentially) over a mean of 14 months. Mean follow-up was 4.2 years in Group I and 3.9 years for Group II. Factors assessed included symptoms, biochemical tests of liver function, diameter of common bile duct stenosis, and complications. In Group I, (34 patients), a total of 162 single stent placement/exchanges were performed (mean 5/patient). In Group II (12 consecutive patients), 8 patients had 4 (10F) stents placed simultaneously, and 4 patients had 5 (10F) stents. At the end of the treatment period, near normalization of biochemical tests of liver function was observed for all patients in Group II, whereas only marginal benefit was noted for patients in Group I. Four patients in Group I had recurrent cholangitis (6 episodes), whereas no patient in Group II had post-procedure cholangitis. In the 12 patients with multiple stents, distal common bile duct stenosis diameter increased from a mean of 1.0 mm to 3.0 mm after treatment; no change in diameter was noted in patients treated with a single stent. Distal common bile duct stenosis secondary to chronic pancreatitis can be treated long term by stent placement. Multiple, simultaneous stents appear to be superior to single stent placement and may provide good long-term benefit. The former resulted in near normalization of biochemical tests of liver function and an increase in distal common bile duct diameter. Multiple stent placement may obviate the need for surgical diversion procedures.

Chirurgische Therapie entzündlicher und maligner Stenosen der distalen Gallenwege

Although there are growing possibilities of interventional endoscopic treatment of benign and malignant stenosis of the distal common bile duct the definitive operative drainage by terminolateral hepaticojejunostomy is in many cases the therapy of choice. In patients with chronic pancreatitis and bile duct stricture the modified duodenum preserving pancreatic head resection ("Beger operation") enables a resection of the inflammatory mass together with a drainage of the bile. Of 391 patients from our clinic being operated due to a bile duct stricture 337 underwent a biliary drainage together with a pancreatic head resection. Early postoperative biliary complications were in 0.3 % strictures of the duct and 1.5 % bile fistulas. Half of those complications could be managed conservatively. In high volume centers the operative therapy of distal common bile duct stenosis is a safe procedure with high patency rate.

Clinical Evaluation of Biliary Tract Lesions in Autoimmune Pancreatitis Using Intraductal Ultrasonography

Autoimmune pancreatitis (AIP) recently was reported as a clinical entity culminating in chronic pancreatitis, with diffuse stenosis of the main pancreatic duct and enlargement of the pancreas causing biliary strictures and jaundice. Clinical reports describing such biliary complications of AIP mainly have been based on endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. We used intraductal ultrasonography (IDUS) to examine biliary lesions in 6 patients with AIP, including changes with treatment in 2. Findings were compared with these in 20 patients without biliary strictures and AIP. We used an ultrasonic probe with a ropeway system, incorporating radial scanning at a frequency of 20 MHz (UM-G20-29R; Olympus, Tokyo, Japan). For 6 IDUS procedures in AIP patients and 10 in non-AIP patients, we used a percutaneous approach; for 2 IDUS procedures in AIP patients and 10 in non-AIP patients, a transpapillary approach was used. Distal common bile duct strictures were seen in all 6 AIP patients; these were classified as diffuse in 3 patients and localized in 3. By IDUS the pancreatic parenchyma showed a coarse, low-echo pattern including focally increased echo in 3 patients, and a low-echo pattern with strong attenuation in 3 patients. These findings differed from those in pancreatic carcinoma. In patients without AIP, mean thickness of the bile duct wall was 1.1 mm when measured by the transpapillary approach, and 1.6 mm by the percutaneous approach (P<0.05 by Student's test). In 3 AIP patients with the diffuse strictures, IDUS measured bile duct thickness as 2.3, 2.8 and 4.0 mm, thicker than control measurements by either a transpapillary or a percutaneous approach. In the 3 patients with localized strictures, bile duct thickness was 3.5, 3.6, and 4.0 mm. In 2 patients treated with a cortico steroid, thickness of the bile duct decreased from 4.0 to 2.0 mm and from 3.6 to 1.4 mm; in 1 of these, cholangiography failed to show improvement of the stricture. IDUS also proved useful in distinguishing biliary strictures caused by AIP from those caused by pancreatic carcinoma. By IDUS, thickness of the bile duct in AIP decreased by half after steroid administration, and this modality could quantitatively evaluate bile duct lesions more accurately than cholangiography.

Ultrasonographic evaluation in patients with autoimmune-related pancreatitis.

The concept of autoimmune-related pancreatitis (AIP) has recently been described. It is important to exclude pancreaticobiliary malignancy in patients with AIP who develop distal bile duct strictures. The aim of this study was to evaluate distal common bile duct strictures in AIP patients by endoscopic ultrasonography (EUS), intraductal ultrasonography (IDUS), and contrast-enhanced EUS (ceEUS). Five patients with AIP, encountered from January 2000 through December 2001, underwent EUS, IDUS, and ceEUS, using Levovist as a contrast medium. EUS and ceEUS were used to follow changes in distal bile duct strictures in three of these five patients following a trial of steroid therapy. Of the five patients, four had cholestatic biochemical profiles, three were positive for autoantibodies, and three had elevated serum immunoglobulin G (IgG) or IgG4. A diffusely enlarged pancreas, narrowing of the main pancreatic duct (MPD), and strictured common bile duct in the pancreatic head were features common to all patients. Pretherapy EUS or IDUS imaging showed concentric wall thickening of the distal common bile duct causing bile duct stenosis. ceEUS showed diffuse strong enhancement of the thickened bile duct wall, possibly due to inflammation. After the steroid therapy, the stenotic lesions in both the MPD and distal common bile duct were rapidly attenuated, with a decline in biochemical cholestatic enzymes and serum IgG or IgG4 levels. On EUS and IDUS imaging, concentric bile duct wall thickening and its strong enhancement by Levovist was characteristic in AIP patients.

ERCP characteristics of 164 patients of hepatocellular carcinoma with obstructive jaundice

AIM: To study the etiology and the manifestation of ERCP in patients of obstructive jaundice with HCC. METHODS: Routine ERCP examinations were performed in 164 cases of hepatocellular carcinoma complicated with obstructive jaundice. Intrahepatic bile duct system was filled as much as possible. Biliary drainage and antibiotics were given routinely after the procedures. RESULTS: Overall, 97.5 % presented as malignant bile duct obstruction and 2.4 % was benign biliary tract lesion. Among malignant obstruction, malignant hepatic hilar and perihilar bile duct stricture were found in 67.7 %, intraductal tumor thrombus in 20.1 %, intraductal thrombus with malignant perihilar stricture in 7.3 %, metastasis of hilar lymph nodes in 1.8 %, retroperitoneal lymph node metastasis in 1.2 %. While in benign lesions, choledolithiasis and distal common bile duct stenosis were found in 1.2 %, respectively. In 110 cases presented as malignant perihilar stricture, 95.4 % were diagnosed as type III and IV. In 33 cases of ductal thrombi, 90.9 % were classified as type III and IV. In 6 cases who were performed papillatomy to remove tumour thrombi, histopathologically, one was diagnosed possibly tumour, one of debris stone and necrotic tissues respectively, two of necrotic tumor tissues and 1 of HCC respectively. Two cases of bile duct cytology were shown exfoliated epithelial cells.

Biliary strictures in pancreatic disease

Pancreatic disease commonly involves the distal common bile duct. Pancreatic adenocarcinoma and chronic pancreatitis are the commonest pancreatic processes resulting in a bile duct stricture. Management of distal common bile duct strictures requires proper diagnosis and appropriate use of both endoscopy and surgery. This article reviews the differential diagnosis and endoscopic managment of biliary strictures in pancreatic disease.

Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents

Background: The long-term efficacy of sequential insertion of multiple plastic stents for benign biliary strictures is poorly defined. The aims of this study were to evaluate the long-term outcome (bile duct patency, complications) of this therapy and to identify predictors of a good outcome. Methods: Retrospective review of 29 cases of benign biliary strictures treated with sequential plastic stent insertion in progressively increasing numbers and/or of increasing diameter. Results: Stricture etiology was as follows: postoperative 19 (66%), chronic pancreatitis 9 (31%), and idiopathic 1 (3%). Therapy succeeded in 18 patients (62%) (mean follow-up 48.0 [11.56] months after stent removal). Therapy failed in 11 patients (38%) (mean interval to failure 11.59 [9.79] months after stent removal). The 2 groups of patients in which therapy failed had either a hilar stricture (n = 4, 25% success) or distal common bile duct stricture caused by chronic pancreatitis (n = 9, 44% success). In the remaining cases, therapy succeeded in 13 of 16 (81% success). The observed differences in success rate among subgroups were not statistically significant. There were no ERCP-related deaths. One episode of mild pancreatitis and 2 episodes of cholangitis developed during 126 ERCPs over a period of stent insertion of 36 patient years. Conclusions: In selected patients with benign biliary strictures, sequential endoscopic insertion of multiple biliary stents may lead to long-term success that could be equal to or superior to surgery with minimal morbidity. Hilar strictures and those caused by chronic pancreatitis appear to respond poorly to this therapy. (Gastrointest Endosc 2002;55:680-6.)

4693 Self-expandable wallstents for distal common bile duct strictures in chronic pancreatitis: follow-up and clinical outcome of 15 patients.

Background: Patients with chronic pancreatitis (CP) and a distal common bile duct (CBD) stricture in whom surgery is not a favorable option, often need frequent exchanges of conventional plastic stents because of stent clogging. In this selected group of patients insertion of a Wallstent may prove to be a valuable alternative to achieve long-term biliary drainage. Methods: All patients presenting with CP and a distal CBD stricture from December 89 to March 99 in whom we inserted a Wallstent were included in this retrospective study. Patients who were alive were contacted and interviewed. Additional information was obtained from family members, general practitioners, and referring physicians. Results: During the study period we inserted 15 Wallstents (1 cm ɸ, 7.8 cm length) in 15 patients (10 men and 5 women, mean age 57 years SD 11). Prior to insertion of the Wallstent, patients had a median of 2 (range 2-27) exchanges of conventional plastic stents. Median patency of these conventional stents was 13 weeks (range 1-47). The primary considerations for placement of a Wallstent were: failure of conventional stent therapy and/or considered not fit for surgery (n=10), patient preference (n=2), suspected malignancy which turned out to be CP (n=2) and unrelated terminal illness (n=1). Median patency of the Wallstent until closure date of the study was 50 weeks (range 1-211). In twelve patients (80%) the Wallstent remained patent until death (n=3, all unrelated causes) or closure date of the study (median follow up 58 weeks, range 6-211) In two patients (13%) the Wallstent became obstructed (1 week, 26 weeks). In one of these patients a conventional plastic stent was inserted through the Wallstent, while in the other patient the Wallstent was removed (the only patient in whom a covered Wallstent was placed) before a conventional plastic stent was reinserted. In one patient (6%) the Wallstent migrated and was retrieved with an overtube. All three patients in whom the Wallstent failed finally underwent a hepaticojejunostomy. The presence of a Wallstent did not hamper the surgical procedure and the final outcomes were uneventful. Conclusions: In a selected group of patients with distal CBD strictures caused by CP in whom conventional stenting is no longer a desirable option and who are not favorable candidates for surgery, insertion of a selfexpandable Wallstent seems to be a safe and effective treatment option. Background: Patients with chronic pancreatitis (CP) and a distal common bile duct (CBD) stricture in whom surgery is not a favorable option, often need frequent exchanges of conventional plastic stents because of stent clogging. In this selected group of patients insertion of a Wallstent may prove to be a valuable alternative to achieve long-term biliary drainage. Methods: All patients presenting with CP and a distal CBD stricture from December 89 to March 99 in whom we inserted a Wallstent were included in this retrospective study. Patients who were alive were contacted and interviewed. Additional information was obtained from family members, general practitioners, and referring physicians. Results: During the study period we inserted 15 Wallstents (1 cm ɸ, 7.8 cm length) in 15 patients (10 men and 5 women, mean age 57 years SD 11). Prior to insertion of the Wallstent, patients had a median of 2 (range 2-27) exchanges of conventional plastic stents. Median patency of these conventional stents was 13 weeks (range 1-47). The primary considerations for placement of a Wallstent were: failure of conventional stent therapy and/or considered not fit for surgery (n=10), patient preference (n=2), suspected malignancy which turned out to be CP (n=2) and unrelated terminal illness (n=1). Median patency of the Wallstent until closure date of the study was 50 weeks (range 1-211). In twelve patients (80%) the Wallstent remained patent until death (n=3, all unrelated causes) or closure date of the study (median follow up 58 weeks, range 6-211) In two patients (13%) the Wallstent became obstructed (1 week, 26 weeks). In one of these patients a conventional plastic stent was inserted through the Wallstent, while in the other patient the Wallstent was removed (the only patient in whom a covered Wallstent was placed) before a conventional plastic stent was reinserted. In one patient (6%) the Wallstent migrated and was retrieved with an overtube. All three patients in whom the Wallstent failed finally underwent a hepaticojejunostomy. The presence of a Wallstent did not hamper the surgical procedure and the final outcomes were uneventful. Conclusions: In a selected group of patients with distal CBD strictures caused by CP in whom conventional stenting is no longer a desirable option and who are not favorable candidates for surgery, insertion of a selfexpandable Wallstent seems to be a safe and effective treatment option.

Cholecystostomy

Strictures, both benign and malignant, of the distal common bile duct (CBD) are reasonably common, and if stented are usually approached endoscopically via the duodenum, or transhepatically via an intrahepatic and then common hepatic duct. We describe a case of endoscopic stenting of a distal CBD stricture over a wire passed percutaneously through the gallbladder, cystic duct and into the duodenum. To our knowledge, this has not been previously described.

Endoscopic treatment of common bile duct strictures complicating chronic pancreatitis

Distal common bile duct (CBD) strictures frequently complicate chronic pancreatitis. These strictures may be noted incidentally at cholangiography or may present as persistent cholestasis, jaundice, or cholangitis. Evaluation of endoscopic biliary stenting for CBD strictures in chronic pancreatitis has been addressed in several studies. These suggest that endoscopic therapy may be a useful alternative to surgery for short-term treatment of these strictures, because immediate relief of jaundice and cholangitis is achieved in nearly all patients. Complete stricture resolution, however, occurs in a minority of patients after final stent removal. Surgical biliary-enteric bypass remains the long-term treatment of choice for average-risk individuals. The role of expandable metallic stents requires further study in this benign condition.

SURGICAL TREATMENT OF CHRONIC PANCREATITIS AND QUALITY OF LIFE AFTER OPERATION

In conclusion, surgical therapy in patients with chronic pancreatitis may be characterized as follows: 1. Independently, several investigators have found intraductal and intraparenchymatous hypertension in patients with chronic pancreatitis. Decompression of the ductal system as the main principle of surgical therapy achieves clinical pain relief in most patients with chronic pancreatitis. The precondition is a consequent drainage of the main pancreatic duct and tributary ducts of second and third order up to the prepapillary region. The presence of an inflammatory tumor in the head of the pancreas or ductal abnormalities in the prepapillary region or a pancreas divisum requires performance of an extended drainage operation (LPJ-LPHE) to achieve pain relief and an improved quality of life. An extended drainage operation effectively manages complications arising from adjacent organs, such as distal common bile duct stenosis, segmental duodenal stenosis, and internal pancreatic fistulas. The extent of decompression has to be tailored to the anatomic and morphologic situation of the patient. 2. In patients with chronic pancreatitis, the main pancreatic duct is usually dilated. A small duct (3-5 mm) is only small for the surgeon. For the sclerosing entity of chronic pancreatitis with a truly small duct, that is, less than 3 mm in diameter ("small duct disease"), a longitudinal V-shaped excision of the ventral pancreas, as opposed to left resection, provides a new perspective for a sufficient drainage. 3. In the presence of segmental portal hypertension, a simple or extended drainage operation does not result in a normalization of the portal venous blood flow; however, how often relevant upper gastrointestinal hemorrhage develops from segmental portal hypertension is unclear. Therefore, the clinical relevance of this special problem needs further evaluation. 4. Postoperative morbidity of LPJ-LPHE is significantly lower in comparison to resectional procedures, such as PD, PPPD, and DPRHP. A lower perioperative mortality rate is not justified anymore as a relevant criterion in favor of drainage procedures because resectional procedures are burdened by a minimal or no mortality in experienced centers; however, PD and PPPD are greatly hampered by a significantly decreased postoperative global quality of life as opposed to the LPJ-LPHE. This is reflected by a significantly lower rate of social and professional rehabilitation. 5. The incidence of exocrine and endocrine organ dysfunction is lower after LPJ-LPHE compared with PD or PPPD, but not compared with DPRHP. Preservation of the gastroduodenal passage and the continuity of the bile duct with its associated feedback mechanisms of exocrine pancreatic secretion and glucose metabolism seem to be responsible for this phenomenon. 6. An early surgical or endoscopic interventional drainage of the hypertensive pancreatic duct system possibly offers the chance to favorably manipulate the natural course of chronic pancreatitis with regard to a delayed onset of exocrine or endocrine insufficiency. 7. Late mortality reflects continued alcohol abuse rather than the effect of an operative procedure.

Incidence and clinical findings of benign, inflammatory disease in patients resected for presumed pancreatic head cancer

Background : The differentiation between cancer and benign disease in the pancreatic head is difficult. The aim of this study was to examine common features in a group of patients that had undergone pancreatoduodenectomy for a benign, inflammatory lesion misdiagnosed as pancreatic head cancer. Methods : Among 220 pancreatoduodenectomies performed on the suspicion of pancreatic head cancer, an inflammatory lesion in the pancreas or distal common bile duct was diagnosed in 14 patients (6%). Of these patients, all preoperative clinical information and radiologic images (ultrasound, endoscopic retrograde cholangio-pancreaticography [ERCP]) were critically reassessed. For each examination, the suspicion of cancer was scored on a 0/+/++ scale. Results : Clinical presentation (pain, weight loss, jaundice) raised a suspicion of cancer in 12 patients. On ultrasound, a tumor (mean size: 2.8 cm) was found in the pancreatic head in 13 patients; 12 of 14 ultrasound examinations raised a suspicion of cancer. ERCP showed a distal common bile duct stenosis (length: 1 to 4 cm), stenosis of the pancreatic duct (length: 1 to 5 cm), or a “double duct” stenosis, suspicious for cancer in 13 evaluable patients. The overall index of suspicion was + in seven patients and ++ in seven patients, confirming the initial interpretation of preoperative data. Conclusion : When undertaking pancreatoduodenectomy for a suspicious lesion in the pancreatic head, it is necessary to expect at least a 5% chance of resecting a benign, inflammatory lesion masquerading as cancer. (Gastrointest Endosc 1997;46:417-23.)

Drainage operation as therapeutic principle of surgical organ saving treatment of chronic pancreatitis

Intraductal and intraparenchymal hypertension represent the rationale for surgical drainage procedures in the treatment of chronic pancreatitis. "Simple" drainage procedures such as longitudinal pancreaticojejunostomy according to Partington-Rochelle have to be distinguished from "extended" drainage operations, e.g. the combination of longitudinal pancreaticojejunostomy with limited local excision of the pancreatic head. This "extended" drainage procedure according to Frey is just as effective as resective procedures in terms of persistent pain relief and definitive management of pancreatitis-associated complications of adjacent organs, i.e. distal common bile duct and duodenal stenosis. This operation also addresses an inflammatory mass in the pancreatic head. In contrast to "simple" drainage procedures the Frey operation allows reliable exclusion of pancreatic carcinoma. With low perioperative morbidity and zero mortality the Frey procedure significantly improves quality of life and leads to social and occupational rehabilitation.

Spontaneous biliary perforation: Does external drainage constitute adequate therapy?

Spontaneous perforation of the biliary tract in infancy is rare; fewer than 100 cases have been reported. The authours report on two patients with spontaneous biliary perforation (SBP) who were treated during the past 5 years. One of the patients, a 10-month-old boy, presented with an extensive retroperitoneal mass, without jaundice. He was found to have a perforation in the pancreatic portion of the common bile duct (CBD). The second patient, a 6-week-old boy, had insidious onset of jaundice, abdominal distension, and acholic stools. He was found to have a perforation at the cystic duct/CBD junction and distal CBD stricture. Both patients initially underwent cholecystostomy and drainage. The second patient had a persistent external biliary fistula and high-grade stricture, and subsequently underwent CBD excision and Roux-en-Y hepaticojejunostomy, at age 12 weeks. The authors' findings do not support the widely held concepts proposing that (1) the diminished distal ductal caliber often associated with these lesions occurs secondary to the perforation rather than is a primary causative factor and (2) the distal biliary obstruction does not require treatment because it resolves with adequate drainage. In the absence of ductal abnormalities, the authors advocate external drainage. For SBP associated with an underlying stricture, prompt biliary intestinal bypass is necessary to avoid biliary cirrhosis and portal hypertension.

Symptomatic duodenal diverticulum.

To determine management guidelines for symptomatic duodenal diverticulum, we reviewed medical records of 26 patients. Complicated duodenal diverticulum was the only possible cause of symptoms-abdominal pain, fever and chills, melena, vomiting-in 18 patients. Ten patients improved with conservative management, and eight patients underwent diverticulectomy with or without various other procedures. Among the eight patients, one patient who had duodenal fistula died of respiratory complications on the second postoperative day. Symptoms recurred in two patients: One had a distal common bile duct (CBD) stricture and underwent choledochojejunostomy. In the other patient a CBD stone developed 3 years later, and choledocholithotomy and choledochojejunostomy were performed. Eight patients had associated gallstone disease as well as the diverticulum. Five of the eight had a history of operation for gallstone disease; four improved with conservative treatment, and one underwent choledochojejunostomy. Two patients were thought to have an innocent diverticulum and underwent cholecystectomy and choledocholithotomy only. One patient underwent diverticulectomy and sphincteroplasty for a CBD stone and pervaterian diverticulum. In conclusion, operations for duodenal diverticulum should be reserved for seriously complicated diverticula, and the surgeon should be aware that pervaterian diverticulum can be a cause of choledocholithiasis.

Hepatobiliary disease in cystic fibrosis patients with pancreatic sufficiency

Focal and multilobular biliary cirrhosis are considered pathognomonic of cystic fibrosis (CF) and almost invariably have been reported in patients with steatorrhea. In contrast, patients with pancreatic sufficiency and normal absorption are considered less likely to develop liver or biliary tract problems. The authors report three patients with CF and pancreatic sufficiency, presenting with recurrent abdominal pain (unrelated to pancreatitis). All had common bile duct disease, one with multilobular cirrhosis and portal hypertension. Pancreatic sufficiency was proven by quantitative pancreatic stimulation tests, 3-day fecal fat analyses, and serum pancreatic isoamylases. All three patients had mild lung disease. Two were homozygous for the common delta F508 mutation, and the other, a delta F508 compound heterozygote. Hepatobiliary structure and function were determined by serial hepatobiliary scintigraphy, percutaneous transhepatic cholecystography, and biochemical liver function tests. Patients 1 and 3 had mild hepatomegaly, normal liver biochemistry, and distal common bile duct strictures. Patient 2 had a firm nodular liver with splenomegaly, abnormal liver biochemistry, and a cholangiographic appearance of sclerosing cholangitis. All have undergone operative treatment for persistent abdominal pain. These cases confirm the occurrence of common bile duct pathology and liver disease in patients with CF and pancreatic sufficiency. They demonstrate that liver and biliary tract disease can occur independently of the underlying disease severity and the presence of steatorrhea. Further, they suggest that obstruction of the biliary tract may be an additional factor in the evolution of liver disease in CF.

Hepatobiliary disease in cystic fibrosis patients with pancreatic sufficiency

Focal and multilobular biliary cirrhosis are considered pathognomonic of cystic fibrosis (CF) and almost invariably have been reported in patients with steatorrhea. In contrast, patients with pancreatic sufficiency and normal absorption are considered less likely to develop liver or biliary tract problems. The authors report three patients with CF and pancreatic sufficiency, presenting with recurrent abdominal pain (unrelated to pancreatitis). All had common bile duct disease, one with multilobular cirrhosis and portal hypertension. Pancreatic sufficiency was proven by quantitative pancreatic stimulation tests, 3-day fecal fat analyses, and serum pancreatic isoamylases. All three patients had mild lung disease. Two were homozygous for the common ΔF508 mutation, and the other, a ΔF508 compound heterozygote. Hepatobiliary structure and function were determined by serial hepatobiliary scintigraphy, percutaneous transhepatic cholecystography, and biochemical liver function tests. Patients 1 and 3 had mild hepatomegaly, normal liver biochemistry, and distal common bile duct strictures. Patient 2 had a firm nodular liver with splenomegaly, abnormal liver biochemistry, and a cholangiographic appearance of sclerosing cholangitis. All have undergone operative treatment for persistent abdominal pain. These cases confirm the occurrence of common bile duct pathology and liver disease in patients with CF and pancreatic sufficiency. They demonstrate that liver and biliary tract disease can occur independently of the underlying disease severity and the presence of steatorrhea. Further, they suggest that obstruction of the biliary tract may be an additional factor in the evolution of liver disease in CF.

Distal common bile duct stenosis secondary to benign duodenal ulceration: Report of a case

Obstructive jaundice is a very rare complication of peptic ulcer disease. We report a patient who presented with symptoms suggestive of malignant distal common bile duct stenosis. A final diagnosis of benign duodenal ulcer with stricture of the common bile duct was made. A short review of the literature is also presented.