Duct Stricture Research Articles

Robotic transduodenal ampullectomy

Background: Our video describes the use of the da Vinci Surgical System Xi® (Intuitive Surgical, Sunnyvale, CA) to perform a transduodenal ampullectomy. The patient is a 61 y.o. female status post cholecystectomy with no history of pancreatitis who presented with chronic abdominal pain. Imaging revealed a dilated common bile duct and relative normal pancreatic duct. She underwent multiple ERCP's with biliary and pancreatic duct stent placement that resulted in the improvement of her abdominal pain. Her workup for malignancy was negative. Results: Diagnostic laparoscopy revealed no findings of overt pathology or malignancy. The round ligament was taken down using the monopolar scissors and left attached to the under surface of the liver. This was later used as a vascularized pedicle flap to cover the resection bed of the liver at the end of the procedure. A Nathanson retractor was used to retract the liver and expose the porta hepatis. The robotic vessel sealer was used to mobilize the gastrocolic ligament and gain access to the lesser sac following which the greater curvature of the stomach was mobilized. The pancreas, and duodenum were grossly normal with no signs of inflammation. Intra operative ultrasound was used to identify the critical vascular structures in the porta hepatis and the common bile duct. It did not show pancreatic duct dilation or stones in this patient. The bipolar vessel sealer was used to mobilize the hepatic flexure and kocherize the duodenum. A 10cm longitudinal duodenotomy was made using the mono polar scissors. The mono polar scissors were used to dissect the ampulla away from the medial wall of the duodenum. Once amputated this was sent for frozen section which was negative. The pancreatic and common bile duct were sutured circumferentially using eight 5-0 monocryl sutures. Seven Fr stents were placed in both ducts. The duodenotomy was closed in Lemberted fashion using three barbed sutures. The round ligament flap was then placed in close proximity to the closure to reinforce it. Conclusion: Intra operative findings were consistent with pancreatic duct stenosis as well as common bile duct stenosis at the ampulla. The patient did well post operatively and recovery was as expected.

Cholangioscopy in diagnosis of diseases of extrahepatic bile ducts

An analysis of the diagnosis of extrahepatic bile duct diseases in 115 patients is presented. With the diagnostic purpose they performed ERCP, EPT, cholangioscopy. The method of direct visualization of the mucous membrane of the bile ducts allows you to identify endoscopic signs of strictures. Differential diagnosis of benign and malignant strictures of the bile ducts using cholangioscopy is difficult. Nevertheless, we were able to identify some typical signs for malignant strictures, including ulceration and mucosal infiltration, vascular pattern irregularity, stricture asymmetry.

Sialendoscopy plus laser lithotripsy in sialolithiasis of the submandibular gland in 64 patients: A simple and safe procedure

ObjectiveTo demonstrate the safety and efficiency of holmium laser-assisted lithotripsy during sialendoscopy of the submandibular gland using a retrospective, interventional consecutive case series. MethodsWe performed 374 sialendoscopies between 2008 and 2015 and evaluated all patients regarding clinical symptoms, clinical findings, therapy and outcome. We performed 109 procedures of holmium laser-assisted lithotripsy in 64 patients whose sialoliths measured 5 mm or more in diameter. In addition to retrospective case note reviews, we performed telephone interviews of all patients in January 2017. ResultsWe performed 374 consecutive submandibular gland sialendoscopy procedures in 276 patients between 2008 to 2015. Sialolithiasis had either previously been diagnosed, or symptoms highly suggestive of sialolithiasis of the submandibular gland presented in 197 patients.Holmium laser-assisted Laser lithotripsy was performed in 109 cases (64.9%). Smaller mobile concrement was removed directly either by forceps or wire basket, or following marsupialisation of the submandibular duct. This was the case in 88 patients (29.1%). Three patients (0.8%) required surgical removal of the submandibular gland due to early abscess. The majority of patients (n = 374 procedures; 90.1%) remained symptom-free after two or more years following intervention. In the remaining procedures (n = 37 procedures; 9.9%), patients reported discreet postprandial problems but did not seek medical attention. In total, we managed to preserve the submandibular gland and avoid open surgery in 99% of patients through endoscopic management of submandibular concrement and duct stenosis. ConclusionHolmium laser-assisted lithotripsy is a simple, safe, and effective procedure for treating patients with sialolithiasis of the submandibular gland. Removal of the gland is rarely required, and removing the gland without prior sialendoscopy is no longer recommended. It should be offered to all patients with submandibular gland sialolithiasis, or such patients should be referred to the appropriate centre for sialendoscopy before submandibulectomy is considered.

Transhepatic forceps biopsy after PTCD for histological assessment of bile duct stenoses or occlusions

The goal of this study was to evaluate the experience of 11 years of wire-guided forceps biopsy via PTCD in patients with obstructive jaundice. In a retrospective approach, 56 biopsies in 51 patients were analyzed (22 female, 29 male). Data was collected from 2006 to 2016. Mean age was 71 years (range: 34 - 86 years). Data was extracted from dig. Patients' records (KIS, PACS, RIS) to be analyzed in Microsoft Excel. All 56 procedures were technically successful. Stenosis in anastomoses were benign due to scarring in 7 patients and in 9 due to papillitis or others. In 4 patients, results in anastomosis were malignant. In 19 patients without anastomosis, CCC was the diagnosis, thereof 10 klatskin, 9 stenosis in other locations, followed by gastric, pancreatic, and colon carcinoma in 5, 3, and 2 patients. Three patients had a CUP (multimetering in case of more than 1 related category). Overall results were 35 mal. and 16 benign, 76.8 % of all proc. had a correct histopathologic result, and 23.2 % were false negative. Sensitivity was 65.8 %, which results in negative predictive value of 58.1 %. There was no false positive and so specificity was 100 %, as was the positive predictive value. False negative results (no malignancy but clinically and imaging suspect) were corrected by rerunning the procedure, by CT-guided biopsy or by 1 PET-CT. In 1 case the surg. sample brought the result. Minor complications occurred in 8patients: shivering in 1case, distinct but hemodynamically not relevant hemobilia in 5 cases, 2 portovenal bleedings. All bleedings were short-term and self-limiting. Despite good feasibility, low peri- and post-interv. risk and high validity the forceps biopsy via PTCD is not widely used. For experienced interventionalists, it is an effective method for obtaining histology.

Endoscopic and surgical treatment of chronic pancreatitis

With an increasing number of hospital admissions, an average of 16-to 20days in hospital per year, 34% of patients constantly taking pain medication, 57% in need of enzyme supplementation, and 29% with diabetes mellitus, chronic pancreatitis is adebilitating disease of high socio-economic relevance. In total, 33% of all patients suffering from chronic pancreatitis can no longer practice their original profession. The number of unemployed chronic pancreatitis patients due to prolonged stays in hospital or continued alcohol abuse is known to be as high as 40%. Continued alcohol abuse with ahazard ratio (HR) of 1.6, smoking with aHR of 1.4, and the presence of liver cirrhosis with aHR of 2.5 negatively affects the prognosis of chronic pancreatitis. In apatient cohort burdened with high co-morbidity, endoscopic therapy can provide short-term relief of symptoms. Endotherapy is the first line of management in chronic pancreatitis with symptomatic pancreatobiliary ductal obstruction. Further studies are required in certain key areas such as the use of fully covered self-expanding metallic stents for pancreatic ductal and biliary strictures. Long-term success rates can mainly be achieved by surgical procedures, which can be performed with acceptable morbidity in pancreatic centers. The current review focuses on the advantages and disadvantages of endoscopic and surgical treatment of chronic pancreatitis.

Ocular Findings in Trisomy 13: Nasolacrimal Duct Stenosis Case Series

Trisomy 13, also known as Patau Syndrome, is a congenital malformation that leads to several ocular anomalies, of which cataracts are the most common, as well as iris and retinal colobomas, persistent hyperplastic primary vitreous, persistent tunica vasculosa lentis, and microphthalmos. While most do not survive beyond the neonatal period, those that do survive past one year of age have an 84% chance of making it to age 5. Therefore, treatments for ocular problems should be used to improve the quality of life if the child can withstand surgery. The literature on this topic has described histopathologic findings in postmortem eyes. This case series supports those observations and presents a new discovery of nasolacrimal duct obstructions or stenosis. Deciding on surgical intervention in cases with Trisomy 13 can be challenging, and a variety of factors must be taken into account before surgery is considered. Treatment of these cases can be difficult, necessitating deliberate consideration and determination on a case-by-case basis; however, this case series gives additional evidence to help guide these decisions. Traditionally, trisomy 13 was regarded as being lethal, multiple organ malformations and severe intellectual disability.

The use of different pathology classification systems in preoperative imaging of Mirizzi syndrome.

IntroductionThe aim was to evaluate the diagnostic value of the Nakagawa and Csendes pathology classification systems in preoperative imaging of Mirizzi syndrome. Mirizzi syndrome is a type of biliary system obstruction caused by stones impacted in a gallbladder neck or cystic duct situated parallel to the common bile duct, causing extrinsic common bile duct stenosis or obstruction, which can lead to recurrent obstructive jaundice, bile duct erosion, and cholangitis. Therefore, the preoperative identification and classification of Mirizzi syndrome is vital for a good surgical result. We explored the applicability of two pathological classification systems to diagnostic imaging.Material and methodsWe performed a retrospective analysis of the clinical, computed tomography, and magnetic resonance imaging data of 76 cases of pathologically confirmed Mirizzi syndrome, comparing the applicability of the Csendes and Nakagawa pathology classification systems to preoperative imaging.ResultsThe Nagakawa pathology classification system had higher sensitivity, specificity, accuracy, positive predictive value, and positive likelihood ratio, along with lower rates of both missed diagnosis and misdiagnosis. Its positive predictive value and positive likelihood ratios were significantly superior. Adapting the Nagakawa pathological classification system to preoperative imaging produced more consistent results than the Csendes system.ConclusionsCompared with the Csendes pathology classification system, the Nagakawa classification is more adaptable to preoperative imaging and treatment planning.

Per-operative modified rigid cholangioscopy for removal of intrahepatic stones associated with choledochal cyst in children.

Introduction:Choledochal cyst (CDC) is often associated with intrahepatic stones (IHSs) in children which necessitate their removal during excision. The endoscopic equipment needed for their clearance such as paediatric flexible cholangioscope and other advanced modalities are not freely available in resource-poor setups. We describe per-operative modified rigid cholangioscopy using rigid paediatric cystoscope for stone removal during open CDC excision.Methods:All children with CDC presenting with IHSs between January 2015 and December 2017 were included in the present study. IHSs were diagnosed by ultrasound/magnetic resonance cholangiopancreatography (MRCP). In these patients, after cyst excision by open technique, a 9 Fr paediatric cystoscope with 4 Fr working channel was inserted into the common hepatic duct for visualisation and clearance of stones from (intrahepatic bile ducts). Follow-up was done using liver function tests, ultrasound and MRCP (if needed). Patients underwent three monthly liver function test and ultrasound and if needed MRCP.Results:Six cases of CDC presenting with IHS were managed, and one case with post-R-en-Y IHS was treated with this technique. Rigid paediatric cystoscope with working channel and forceps was used. All cases were successfully managed, and one case was found to have intrahepatic duct stenosis was dilated.Conclusion:Per-operative rigid endoscopy using paediatric cystoscope is an easily available tool in most of the setups for the management of IHS associated with CDC in children.

Human fibrin sealant reduces post-operative bile leakage of primary closure after laparoscopic common bile duct exploration in patients with choledocholithiasis.

Context:Primary closure of the common bile duct (CBD) without drainage is considered a suitable approach after laparoscopic CBD exploration (LCBDE); however, the risk of post-operative bile leakage is high. Up to now, it has not been clear whether human fibrin sealant can reduce post-operative bile leakage of the primary suture.Aims:In this study, we evaluated the role of human fibrin sealant in primary closure of the CBD after LCBDE.Subjects and Methods:Patients with choledocholithiasis who had undergone primary duct closure of the CBD after LCBDE were divided into two groups according to whether fibrin sealant was used.Statistical Analysis Used:Fisher's exact test or the Chi-square test was used for categorical variables to calculate frequencies and percentages between the groups. The Student's t-test was used to compare the means of the continuous variables between the groups.Results:The human fibrin sealant group had a lower rate of post-operative bile leakage compared to the other group (P < 0.05). There were no significant differences in additional parameters such as operative time, post-operative stay duration, time to drain removal, bile duct stenosis, acute allergic reaction and overall mortality.Conclusions:Human fibrin sealant can reduce post-operative bile leakage in primary closure of CBD after LCBDE in patients with choledocholithiasis.

Risk Factors for Pancreatic Stone Formation in Type 1 Autoimmune Pancreatitis: A Long-term Japanese Multicenter Analysis of 624 Patients.

Autoimmune pancreatitis (AIP) has the potential to transform into chronic pancreatitis with pancreatic stone involvement. This retrospective investigation sought to clarify the risk factors for stone formation in type 1 AIP. Questionnaires on patients with type 1 AIP were sent to 22 high-volume medical centers across Japan to compare the clinical features of patients with and without pancreatic stone formation. Of the completed records on 624 type 1 AIP patients, 31 (5%) had experienced pancreatic stones. Median follow-up duration was 1853 days. Bentiromide test values at diagnosis were significantly lower, and hemoglobin A1c values after corticosteroid treatment were significantly higher in patients with pancreatic stones. Imaging results disclosed that pancreatic atrophy and hilar or intrahepatic bile duct stenosis were significantly more frequent in patients with pancreatic stone formation. Pancreatic head swelling tended to be more frequent in this group as well. On the other hand, a shorter follow-up period was associated with the nonformation of pancreatic stones. The increased frequency of pancreatic head swelling in type 1 AIP patients exhibiting pancreatic stones indicated a propensity for pancreatic juice stasis with subsequent stone development and pancreatic dysfunction occurring over longer periods of disease duration.

The role of percutaneous transhepatic biliary biopsy in the diagnosis of patients with obstructive jaundice: an initial experience.

ObjectiveTo evaluate the accuracy of percutaneous transhepatic biliary biopsy (PTBB) in patients with suspected biliary obstruction.Materials and methods This was a retrospective analysis of 18 patients with obstructive jaundice who underwent PTBB. In each patient, three to ten fragments were collected from the lesion. The final diagnosis was confirmed in the pathology report. We also reviewed analyses of the results of laboratory tests performed before the procedure, as well as the Bismuth classification, clinical outcome, complications occurring during the procedure, access route, and materials used.ResultsTechnical success was achieved in 100% of the PTBB procedures. Among the 18 patients clinically diagnosed with bile duct stenosis, the pathological analysis confirmed that diagnosis in 17. In one case, the pathological findings were considered false-negative. The predominant tumor was cholangiocarcinoma (seen in 50% of the cases). Sixteen of the procedures (88.9%) were performed without complications. Transient hemobilia occurred in one case, and cholangitis occurred in another.ConclusionPTBB is a safe, viable, simple technique with a high rate of true-positive results for the definitive diagnosis of obstructive jaundice.

In case of bile duct-bowel anastomosis, in which case should the stent be placed? - Examination by biliary regeneration model using artificial bile duct -

Introduction: In case of bile duct-bowel anastomosis, it is not sufficiently studied in what cases the stent should be placed. In this study, a method for diagnosing bile duct stenosis after bile duct injury from a biliary regeneration model using a bioabsorbable bile duct tube (artificial bile duct:ABD) was examined histologically. Method: (Biliary regeneration model) An ABD is implanted so as to bypass the extrahepatic bile duct and duodenum, the bile duct regenerates (Am J Transplant 2005). In this model, in most cases, after the ABD has been absorbed, the bile duct regenerates at the site where the ABD has been implanted. However, in rare cases, the anastomotic portion between the ABD and the natural bile duct may be narrowed. Histological examination of these narrowed bile duct epithelium was performed. Result: There are two types of tissue on the surface of the stenosing bile duct epithelium. A: The bile duct epithelium is detached and only the fibrous connective tissue is observed on the epithelial surface. B: The bile duct epithelium has fallen, but a structure like a small bile duct adherent gland is seen in the lower layer of the epithelial surface. Conclusion: There are two kinds of bile duct narrowing. First, the bile duct narrows due to fibrous tissue without good bile duct regeneration process from the early stage of bile regeneration. Secondly, in the early stage of regeneration of the bile duct, accessory glands of the bile duct was formed, but it was found that there was a state in which the regeneration process did not progress well in the regeneration process of the bile duct epithelium. By the initiation of treatment after bile duct injury, early biopsy and diagnosis of early bile duct epithelial tissue could diagnose early bile duct stricture and make it possible to treat early.

Biliary duct stenosis after image-guided high-dose-rate interstitial brachytherapy of central and hilar liver tumors : Asystematic analysis of 102 cases.

Image-guided high-dose-rate interstitial brachytherapy (iBT) with iridium-192 is an effective treatment option for patients with liver malignancies. Little is known about long-term radiation effects on the bile duct system when central hepatic structures are exposed to iBT. This retrospective analysis investigates the occurrence of posthepatic cholestasis (PHC) and associated complications in patients undergoing iBT. We identified patients who underwent iBT of hepatic malignancies and had point doses of ≥1 Gy to central bile duct structures. Patients with known bile duct-related diseases or prior bile duct manipulation were excluded. 102 patients were retrospectively included. Twenty-two patients (22%) developed morphologic PHC after amedian of 17 (3-54) months; 18 of them were treated using percutaneous transhepatic cholangiopancreatography drainage or endoscopic retrograde cholangiopancreatography. The median point dose was 24.8 (4.4-80) Gy in patients with PHC versus 14.2 (1.8-61.7) Gy in those without PHC (p = 0.028). Adose of 20.8 Gy (biological effective dose, BED3/10 = 165/64.1 Gy) was identified to be the optimal cutoff dose (p = 0.028; 59% sensitivity, 24% specificity). Abscess/cholangitis was more common in patients with PHC compared to those without (4 of 22 vs. 2 of 80; p = 0.029). Median survival did not differ between patients with and without PHC (43 vs. 36months; p = 0.571). iBT of liver malignancies located near the hilum can cause PHC when the central bile ducts are exposed to high point doses. Given the long latency and absence of impact of iBT-induced PHC on median survival, the rate of cholestasis and complications seen in our patients appears to be acceptable.

Postprandial bile acid levels in intestine and plasma reveal altered biliary circulation in chronic pancreatitis patients

Bile acid (BA) secretion and circulation in chronic pancreatitis (CP) patients with exocrine pancreatic insufficiency (EPI) were investigated by simultaneously measuring postprandial levels of individual BAs in duodenal contents and blood plasma using LC-MS/MS. CP patients and healthy volunteers (HVs) were intubated with gastric and duodenal tubes prior to the administration of a test meal and continuous aspiration of duodenal contents. Pancreatic lipase outputs in CP patients were very low (0.7 ± 0.2 mg) versus HVs (116.7 ± 68.1 mg; P < 0.005), thus confirming the severity of EPI. Duodenal BA outputs were reduced in CP patients (1.00 ± 0.89 mmol; 0.47 ± 0.42 g) versus HVs (5.52 ± 4.53 mmol; 2.62 ± 2.14 g; P < 0.15). Primary to secondary BA ratio was considerably higher in CP patients (38.09 ± 48.1) than HVs (4.15 ± 2.37; P < 0.15), indicating an impaired transformation of BAs by gut microbiota. BA concentrations were found below the critical micellar concentration in CP patients, while a high BA concentration peak corresponding to gallbladder emptying was evidenced in HVs. Conversely, BA plasma concentration was increased in CP patients versus HVs suggesting a cholangiohepatic shunt of BA secretion. Alterations of BA circulation and levels may result from the main biliary duct stenosis observed in these CP patients and may aggravate the consequences of EPI on lipid malabsorption.

Endoscopicretrograde cholangio-pancreatography management of long-term complications after pancreaticoduodenectomy

Objective: To investigate the feasibility and effectiveness of endoscopicretrograde cholangio-pancreatography(ERCP)in the management of long-term complications after pancreaticoduodenectomy. Methods: From January 2009 to July 2018, the clinical data of 62 patients with biliary or pancreatic long-term complications after pancreatoduodenectomy were reviewed at Department of General Surgery, and the corresponding ERCP were carried out in the multi-disciplinary cooperation.There were 39 males and 24 females.The age was 56.5 years(aging from 13 to 76 years). The time of treatment was 3 months to 20 years after pancreatoduodenectomy.The long-term biliopancreatic complications after pancreatoduodenectomy included 51 cases of biliary calculi, 42 cases of bilioenteric anastomotic stenosis with proximal bile duct dilatation, and 11 cases of pancreaticointestinal anastomosis stenosis with distal pancreatic duct dilatation.All patients received conventional duodenoscopy or single-balloon enteroscopy assisted ERCP under general anesthesia. Results: A total of 95 ERCP were performed in 62 patients, averaging 1.5 times per case.The long-term complications of cholangiopancreatic after pancreatoduodenectomy(ERCP indications) included 56 times of bile duct stones(58.9%), 45 times of bilioenteric anastomatic stricture(47.4%), 11 times of recurrent pancreatitis(11.6%), 6 cases(6.3%) of bilioenteric anastomatic foreign body, 3 times of intrahepatic bile duct stenosis(3.2%). Among the 95 times, 82 times(86.3%) achieved endoscopic endoscopy, 76 times(80.0%) were diagnosed successfully, and 72 times(75.8%) were successfully treated with ERCP.Small intestinal perforation occurred in 1 patient undergoing duodenoscopy, and then healed by surgical repair. Conclusion: Multi-disciplinary collaboration of ERCP is safe and effective in the treatment of long-term complications after pancreaticoduodenectomy, but the long-term effect still needs further clinical follow-up.

Evaluation of Parotid Gland Function Before and After Endoscopy-Assisted Stone Removal

To quantify gland function before and after endoscopy-assisted lithectomy for patients with parotid stones and to analyze correlations among different evaluation modalities. This study investigated 58 patients (27 men and 31 women) with a stone larger than 5mm or multiple parotid stones who underwent successful endoscopy-assisted surgery at the authors' center from August 2007 through September 2017. Meticulous postoperative manipulations were administered routinely for 3 to 6months to promote functional recovery of the affected gland. Glandfunction was evaluated preoperatively and 6 to 36months (mean, 12months) postoperatively by sialography, scintigraphy, and sialometry. Statistical analyses were conducted to quantify gland function recovery and to distinguish correlations among the 3 objective tests. Preoperative sialograms exhibited ductal ectasia at the stone site with ductal stenosis anterior to the stone (n=53) or duct interruption at the stone site (n=5). Postoperative sialograms of 45 patients without stones were categorized as approximately normal (type I; n=17); showing ectasia or stenosis of the main duct without persistent contrast on the functional film (type II; n=16); showing ectasia or stenosis of the main duct with mild contrast retention (type III; n=6); or showing poor ductal shape with evident contrast retention (type IV; n=6). Scintigraphy of 23 preoperative and 12 postoperative patients and sialometry of 24 preoperative and 12 postoperative patients indicated severe preoperative impairment and postoperative improvement of gland function. Postoperatively, although no relevant differences in saliva flow rate were found between the 2 sides, scintigraphy showed lower function of the affected gland compared with the control side. Statistical data showed positive correlations among the 3 methods. Sialography intuitively reflected the ductal shape, whereas sialometry and scintigraphy were more sensitive for evaluating gland function. For patients with parotid stones, minimally invasive endoscopic surgery and meticulous postoperative manipulations help preserve the glands and facilitate recovery of gland function. The 3 evaluating modalities have certain positive correlations.

Rare case of idiopathic sclerosing cholangitis, which was difficult to distinguish from cholangiocarcinoma: A case report.

It is often difficult to correctly diagnose patients who present with dilation of the bile duct. Cholangiocarcinoma, primary sclerosing cholangitis (PSC) and immunoglobulin (Ig)G4-related sclerosing cholangitis must be considered as potential diagnoses for these cases. The current study presents a 73-year-old female patient who presented with a high fever and abdominal pain. Contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography revealed stenosis and dilation of the intrahepatic bile duct without solid components. It was suspected that the patient had intrahepatic cholangiocarcinoma. A left liver lobectomy, cholecystectomy and distal gastrectomy combined with a D2 lymph node dissection were performed. A pathological examination of the liver revealed increased fibrosis in the stroma, irregular bile duct dilation and clusters of inflamed lymph cells. No carcinoma or IgG4-positive plasma cells were observed and the typical findings of PSC were not detected. Based on these clinical and pathological results, the diagnosis was idiopathic sclerosing cholangitis, which is particularly rare. It is often difficult to preoperatively differentiate between cholangiocarcinoma and benign bile duct stenosis.

Curious Case of a Middle Common Bile Duct (CBD) Stricture Found on Endoscopic Retrograde Cholangiopancreatography

Curious Case of a Middle Common Bile Duct (CBD) Stricture Found on Endoscopic Retrograde Cholangiopancreatography

Celiac Disease in a Patient with Ulcerative Colitis and Primary Sclerosing Cholangitis

Celiac disease (CD) has been found in 2-3% of patients with PSC. There is a known association between Ulcerative Colitis and PSC. Studies show that 2-7.5% of patients with UC develop PSC. The combination of CD, UC, and PSC is even more uncommon. This is a case of a 57-year-old woman with history of UC and PSC who was found to have CD on annual endoscopy. Patient is a 57-year-old Caucasian woman with history of UC/PSC who presented for annual EGD/colonoscopy. She was initially diagnosed with UC by colonoscopy at age 40 after a one-year history of recurrent diarrhea. Since then, she has been managed on Apriso with yearly colonoscopies. At age 46, she was diagnosed with PSC after a cholestatic liver profile prompted ERCP, which revealed focal left intrahepatic ductal stricture. Since then, she has been managed on Actigall and follows up with Hepatology every 6 months. Five years later, she was found to have advanced liver disease secondary to her PSC when ERCP revealed dominant biliary stricture. Two years later, at age 54, she was found to have small proximal esophageal varices on endoscopy, which portended advancement of liver disease with significant portal hypertension. Esophageal varices were controlled with endoscopic ligation. Subsequent endoscopies have been negative for esophageal varices. On her annual EGD, she was found to have duodenal irregularity; subsequent biopsies revealed blunting of villi. She was diagnosed with CD, complicating her PSC and UC. Her CD is currently being managed by gluten-free diet. PSC and UC have a long-standing known association. Both conditions are autoimmune in nature with p-ANCA positivity. Classically, they present together in middle-aged men; their presentation in a woman makes our case unique to begin with. PSC and CD have a less well-known association, most likely due to immunologic connection. However, very few previous case studies have examined association and clinical outcomes between UC and co-existing CD. According to Giovanni et al., IBD could obfuscate the symptoms of CD because they share common symptoms such as weight loss, abdomen pain, and diarrhea. Another prior case series of IBD patients with CD found that 4/5 of these patients with co-existing UC and CD tend to have pancolitis. However, these patients did not have PSC. Thus, our patient with all three conditions co-existing together represents a unique case as there is limited knowledge regarding the course of UC in patients with both PSC and CD.

PANCREATIC-PLEURAL FISTULA PRESENTING AS RECURRENT UNILATERAL PLEURAL EFFUSION

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pancreatic-pleural fistula (PPF) is a rare complication of pancreatitis. Pleural effusion seen with pancreatitis is usually clinically insignificant but PPF can produce recurrent and large volume pleural effusions. CASE PRESENTATION: A 58-year-old male with a medical history significant for alcohol abuse and recurrent alcoholic pancreatitis presented to our institute with worsening shortness of breath for 2 days.He was recently admitted for the third time to the hospital with similar presentation and was diagnosed with massive left-sided pleural effusion requiring drainage for symptom relief. He started feeling short of breath the very next day after discharge, more on exertion. On admission, his vitals were: HR 118, BP 140/97, RR 22, Temp 98.2F. Physical examination was remarkable for dullness to percussion with reduced air entry up to the left 5th intercostal space.Laboratory workup revealed a serum lipase level of > 600 U/L, serum amylase of 459 U/L mm/hr.Chest x-ray showed opacification of left hemithorax. CT chest confirmed large left-sided pleural effusion with compression collapse of the left lower lung.Pleural fluid analysis showed an exudative effusion with an amylase level of 17675 U/L. MRCP of the abdomen revealed diffusely dilated pancreatic ducts.Despite repeated aspiration, recurrent accumulation of pleural effusion was seen, so a chest tube was inserted.An ERCP was performed for the concern of pancreatic-pleural fistula which was consistent with moderate ductal stenosis and contrast extravasation from the ventral pancreatic duct in the head of the pancreas but did not demonstrate a clearcut fistulous tract. A stent was placed in the stenotic duct. The pleural fluid drainage from the tube decreased markedly, the chest tube was removed next day and a follow-up chest X-ray after 2 weeks revealed no evidence of recurrent pleural effusion. DISCUSSION: Although uncommon, pancreatic-pleural fistula can present with recurrent unilateral clinically significant pleural effusion. Although there is no cutoff level to establish the diagnosis, pleural fluid amylase is usually greater than 1000U/L, with levels of> 50,000U/L highly suggestive of a PPF.ERCP is essential in both the diagnosis and treatment of PPF; it does not only show the site of the leak but also reveals the ductal morphology, it demonstrates the fistulous tract in 59% to 74% of the cases. In our patient, the diagnosis was initially suggested by the very high level of pleuritic fluid amylase level and was confirmed by imaging and ERCP. Treatment was successful after a stent was placed at the site of leakage. CONCLUSIONS: Pancreatic-pleural fistula (PPF) should be included in the differential diagnosis of recurrent and large pleural effusions especially in middle-aged men with a history of alcohol consumption and recurrent pancreatitis. Reference #1: A. R. Dhebri and N. Ferran, “Nonsurgical management of pancreaticopleural fistula,” Journal of the Pancreas, vol. 6, no. 2, pp. 152–161, 2005. Reference #2: R. Materne, P. Vranckx, C. Pauls, E. E. Coche, P. Deprez, and B. E. Van Beers, “Pancreaticopleural fistula: diagnosis with magnetic resonance pancreatography,” Chest, vol. 117, no. 3, pp. 912–914, 2000. Reference #3: E. W. Pottmeyer, C. F. Frey, and S. Matsuno, “Pancreaticopleural fistulas,” Archives of Surgery, vol. 122, no. 6, pp. 648–654, 1987. DISCLOSURES: No relevant relationships by Taha Ahmed, source=Web Response No relevant relationships by TALHA AHMED, source=Web Response No relevant relationships by Basma Ricaurte, source=Web Response