Extrahepatic Biliary Tract Obstruction Research Articles

A STUDY ON CLINICAL CHARACTERISTICS OF ACUTE CHOLECYSTITIS AND ITS RELATION WITH ELEVATED LIVER ENZYMES AND BILIRUBIN

ntroduction: Acute cholecystitis is the most common complication in a gallstone disease and remains one of the most common medical problems leading to surgical intervention. The clinical picture of the patients with acute cholecystitis is further complicated by deranged liver function tests due to inammatory process induced by cholecystitis.74Liver damage in patients with gallstones is thought to be the result of chronic extra hepatic biliary tract obstruction with or without repeated episodes of cholangitis.69However, a few studies have reported the presence of hepatocellular injury in patients with acute cholecystitis without choledocholithiasis.70,38We conducted this study further to demonstrate any relation of gallstones with deranged liver function. This tertiary clinic based prospective observational study on 100 patients of gallMethods: stone disease diagnosed on imaging, was conducted at the Department of Surgery, Silchar Medical College and Hospital from 7th June 2018 to 6th June 2019.All routine tests with special reference to Total Leucocyte and Differential Leucocyte counts and Liver function tests- with special reference to serum bilirubin and fraction, Serum AST, ALT, ALP,GGT were obtained and statistical analysis performed to demonstrate their inter- relationship with gallstone disease. On the day of admission (day-0), 32 patients (15.62% male & 84.37% female) had increased level ofResult: AST. Similarly, ALT was increased in 49 patients (20.4% male & 79.59% female), ALP was increased in 32 patients (15.62% male & 84.37% female), GGT was increased in 38 patients (26.31% male & 73.6% female).All four liver enzymes were increased in 32% patients (12.5% male & 87.5% female). Total Bilirubin was increased in 17 patients out of which 35.29% were Male and 64.7% were Female. Direct Bilirubin was increased in 26% patients (9 Males and 17 Females). Total Leucocytic count was increased in 60 patients out of which 14(23.3%) were Males and 46(76.6%) were Females. On the day of admission, AST was found to be in the range of 19U/L- 116U/L in the study population with a mean value of 48.10+27.59 and median value of 37.50.ALT was found to be in the range of 3U/L-141U/L in the study population with a mean value of 56.33+33.75 and median value of 40. ALP was found to be in the range of 60U/L-234U/L in the study population with a mean value of 117.58+39.64 and median value of 100.50. GGT was found to be in the range of 22U/L- 154U/L in the study population with a mean value of 74.66+30.05 and median value of 69.50. The mean values of Liver enzymes, Bilirubin (Total & Direct) and TLC were found to be signicantly decreased on 6 weeks after admission. Liver enzymes and bilirubin tend to marginally increase in few cases of acute cholecystitis asConclusion: a result of the inammatory process. However, this increase is transient and the levels come down to normal once the inammatory process of acute cholecystitis subsides.

English

BACKGROUND Extra-hepatic biliary tract obstruction can be due to a number of conditions. Most causes are due to stones in the common biliary duct or due to malignant obstruction. Malignant causes include carcinoma head of pancreas, periampullary carcinoma and cholangiocarcinoma. Besides calculus and malignant obstruction, benign and malignant strictures can also cause obstruction of extra hepatic biliary ducts. The objectives of the study were to describe the clinical profile of patients presenting with extra-hepatic biliary obstruction and to assess the known aetiological factors. METHODS The research was designed as a hospital based cross-sectional study in the general surgery wards of our institution from 2016 to 2017. All individuals who were diagnosed to have extra-hepatic biliary obstruction by imaging were included in the study. RESULTS Among the 66 cases studied, majority were due to malignancies and gall stones. The malignancies included carcinoma head of pancreas, periampullary carcinoma, cholangiocarcinoma and Klatskin’s tumour. Miscellaneous causes were bile duct stricture, cholelithiasis with biliary sludge and annular pancreas. For the malignant cases, Whipple surgery and its pylorus-preserving variant were the most common surgical procedures carried out. Biliary bypass procedures were also carried out in some patients. For patients with common bile duct (CBD) stones, cholecystectomy, choledocholithotomy and choledochojejunostomy were done. CONCLUSIONS Malignant causes of jaundice are more common than benign causes. Secondary stones are the commonest cause of non-malignant biliary obstruction. Jaundice is more severe and associated with pruritis and more intolerable and persistent in malignancy. Surgical bypass procedures give good palliation for obstructive jaundice. KEY WORDS Bile Ducts, Choledocholithiasis, Cholestasis, Extra Hepatic, Pancreatic Cancer, Periampullary Cancer

Development of a non-functional pancreatic neuroendocrine tumor and a duodenal ulceration after cholecystoduodenostomy in a cat

A six-year-old Ragdoll with previous extrahepatic biliary tract obstruction due to cholangiohepatitis, treated with cholecystoduodenostomy, was presented for acute vomiting, hyporexia, and weight loss. Abdominal ultrasound examination revealed randomly distributed hepatic nodules and dilated biliary ducts. Gastroduodenoscopy showed a patent cholecystoduodenostoma but disclosed a perforated duodenal ulceration. Conversion to celiotomy revealed extensive liver pathology, a discrete pancreatic nodule, and a duodenal ulcer opposite to the cholecystoduodenostoma. The cat was euthanized intra-operatively and necropsy was performed. The intrahepatic biliary tract of the right liver lobes was obstructed and severely dilated, whereas bile from the left lobes drained through the cholecystoduodenostoma. Histopathologic diagnoses were a primary pancreatic tumor, positive for glucagon on immunohistochemistry, with liver metastases, chronic purulent cholecystitis, and duodenal ulceration. To the authors’ knowledge, this is the first report in which the development of pancreatic neoplasia is described in a cat with a history of biliary tract disease.

Extrahepatic biliary tract obstruction secondary to a diaphragmatic rent in a dog

A 13-month-old intact female Akita was referred to a specialty hospital with suspected pancreatitis. Radiographs at the time of presentation showed atypical positioning of the pylorus and proximal descending duodenum,...

SCORE SYSTEM FOR ERCP INDICATING IN EXTRAHEPATIC BILE DUCT OBSTRUCTION

Abstracts. Aim: to objectify indications for urgent/emergency ERCP in patients with extrahepatic biliary tract obstruction (EBTO) by using the score system
 Matherials and Methods. The score is used by summing the points: hyperthermia ≥ 37.3 ° C (1 point); one of three hematological points — leukocytosis ≥ 9×109/l or stab neutrophils ≥ 7% or the ratio of the number of segmented and stab neutrophils <10 (1 point); two biochemical — serum bilirubin ≥ 70 μmol / l (1 point), hyperamylasemia (1 point); thickening of the gallbladder wall ≥ 4 mm or shrunken gallbladder (1 point); the main pancreatic duct dilatation (1 point); in the presence of a periampular tumor or signs of chronic pancreatitis, one point is subtracted (- 1 point).
 The scale was tested on 171 patients with EBTO.
 Results. The threshold value of the scale was ≥3 points (p <0.001). The number of points (3, ≥4) correlated with the severity of acute cholangitis and acute biliary pancreatitis (p <0.01).
 Conclusions. In patients with confirmed OEDB in case of ≤2 points of the score system — urgent/emergency ERCP is not indicated; in case of ≥3 points — urgent ERCP is indicated; in case of ≥4 points emergency ERCP should be performed.

Imaging diagnosis of extrahepatic biliary tract obstruction with acquired portosystemic shunt in a cat

Imaging diagnosis of extrahepatic biliary tract obstruction with acquired portosystemic shunt in a cat

Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study

ERCP-guided biliary drainage (ERCP-BD) is a criterion standard treatment for malignant biliary obstruction when curative surgery is not an option. Alternative methods such as percutaneous transhepatic biliary drainage would significantly lower the quality of life. EUS-guided biliary drainage (EUS-BD) has been developed and performed by experienced endoscopists. Therefore, the aims of this studywere to evaluate the efficacy and safety of EUS-BD compared with ERCP in malignant biliary obstruction. The prospective randomized controlled study was conducted, and 30 patients were enrolled: 15 for each EUS-BD and ERCP-BD arms. The technical success, procedural time, clinical success, and adverse events were evaluated. Thirty patients had extrahepatic malignant biliary tract obstruction (19 men, 11 women). Twenty-seven patients had unresectable pancreatic ductal adenocarcinomas, 1 patient had distal common bile duct cancer, and 2 patients had metastatic malignant lymphadenopathy. There were no significant differences both in terms of technical success rate and clinical success rate (100% vs 93% and 93% vs 100% in ERCP-BD vs EUS-BD, respectively; P= 1.00, P= 1.00). Four patients (31%) had tumor ingrowth-caused stent dysfunction in the ERCP-BD group, whereas 2 patients had food impaction and 2 patients had stent migration in the EUS-BD group. No significant procedure-related adverse events occurred in either group. This prospective randomized controlled study suggests that EUS-BD has similar safety to ERCP-BD. EUS-BD was not superior to ERCP-BD in terms of relief of malignant biliary obstruction. EUS-BD may have fewer cases of tumor ingrowth but may also have more cases of food impaction or stent migration. (Clinical trial registration number: NCT01421836.).

Extrahepatic Biliary Obstruction Secondary to Traumatic Diaphragmatic Hernia in Dog

A 3-year-old intact mixed hunting dog was referred to Gyeongsang Animal Medical Center with the clinical signs of vomiting, dyspnea, anorexia. The dogs had traumatic history that wounded at abdominal wall during the wild boar hunting 2 week ago. The dogs was diagnosed as extrahepatic biliary tract obstruction (EHBO) secondary to traumatic hernia. Diagnosis was based on radiographic features of a diaphragmatic hernia on survey radiography, dilated bile duct in abdominal ultrasonography and complete recovery due to the return of displaced organs into the peritoneal cavity and repair of the diaphragmatic rent. Diagnostic imaging and surgical intervention may result in a favorable outcome in dog with post hepatic obstruction secondary to diaphragmatic hernia. This case emphasizes the strangulation of bile duct by diaphragmatic rupture could be the cause of EHBO.

Clinical forum: canine pancreatitis and biliary duct obstruction

Part 3: The surgeon's perspective The first two of these three articles have looked at the issues of management of extrahepatic biliary tract obstruction from diagnostic and therapeutic view points. By the time the case has been transferred to the surgical team, the patient may still be in a critical condition. Extra hepatic biliary duct obstruction (EHBDO) has a number of systemic physiologic effects, other than the obvious clinical sign of jaundice ( Figure 1 ). Patients may be inappetant, and in a cachectic condition, they may have an anaemia of chronic disease, intestinal sloughing or haemorrhage, hepatic compromise, coagulopathy, endotoxaemia, decreased myocardial contractility, acute tubular necrosis and be at risk of biliary tract rupture.

Evaluation of coagulation in dogs with partial or complete extrahepatic biliary tract obstruction by means of thromboelastography

To characterize in vitro coagulation status in a cohort of dogs with extrahepatic biliary tract obstruction (EHBO) and to evaluate these patients for hypercoagulability by means of thromboelastography. Prospective cohort study. Animals-10 dogs with EHBO and 19 healthy control dogs. Partial or complete EHBO was confirmed via exploratory celiotomy. Venous blood samples were collected for evaluation of prothrombin time (PT) and activated partial thromboplastin time (APTT); fibrinogen and D-dimer concentrations; protein C and antithrombin activities; and factor VII, VIII, and XI coagulant activities in plasma as well as thromboelastography in whole blood. Thromboelastography variables were measured from the thromboelastography tracing, and a coagulation index was calculated. Thromboelastography results were compared with those of healthy control dogs previously evaluated by the same laboratory. Hypercoagulability was diagnosed in all dogs with EHBO on the basis of a high coagulation index. Thromboelastography variables, including maximal amplitude, α-angle, and coagulation index, were significantly higher, and K (clot formation time) and R (reaction time) were significantly lower in these dogs than in control dogs. All dogs with EHBO had PT and APTT within respective reference ranges. Plasma D-dimer and fibrinogen concentrations were above reference ranges in 8 and 7 dogs, respectively, and protein C and antithrombin activities were below reference ranges in 3 and 1 dogs, respectively. In vitro hypercoagulability was commonly detected in dogs with naturally occurring EHBO. The traditional view of EHBO as a disease that causes hypocoagulability may need to be reconsidered.

A Rare Cause for Extrahepatic Biliary Tract Obstruction: Juvenile Hepatic Hilar Hemangioma

A Rare Cause for Extrahepatic Biliary Tract Obstruction: Juvenile Hepatic Hilar Hemangioma

Extrahepatic biliary tract obstruction in two ferrets (Mustela putorius furo)

This report describes extrahepatic bile duct obstruction in two ferrets, which were presented with anorexia, chronic weight loss and general weakness. Physical examination revealed lethargy, cachexia, dehydration, abdominal pain and icterus. Marked haematological, serum chemistry and urinalysis abnormalities included hyperbilirubinaemia (65·5 and 114·2 μmol/L), high concentrations of alanine transaminase (1327·53 and 2578·88 IU/L) and biluribinuria. Abdominal ultrasonography revealed thickening of the bile duct together with the gall bladder wall. The common bile duct was obviously distended. Choledochotomy revealed inspissated bile with fragile green gelatinous plugs that was removed to allow the bile to flow into the duodenum. Cytology and culture of the biliary tract contents were negative for bacteria. Laboratory analyses of biliary plugs showed presence of only protein substances, without detectable mineral composition. Histopathological examination of the liver showed diffuse steatosis and non-specific cholangiohepatitis in both cases.

Eosinophilic cholangitis with obstructive jaundice mimicking bile duct carcinoma

A 55-year-old male who presented with obstructive jaundice and radiographically documented extrahepatic biliary tract obstruction is reported. Eosinophilic infiltration of the gallbladder, common bile duct, intrahepatic bile ducts, and bone marrow was observed. Eosinophilic cholangitis, a rare inflammatory condition that clinically resembles a biliary malignancy, should be taken into consideration in the differential diagnosis in the evaluation of presumed neoplasm of the bile ducts.

Treatment of pancreatitis‐associated extrahepatic biliary tract obstruction by choledochal stenting in seven cats

To report the clinicopathological findings and outcome in cats with pancreatitis-associated extrahepatic biliary tract obstruction (EHBO) treated by choledochal tube stenting. Medical records of cats with EHBO secondary to pancreatitis that underwent choledochal stenting were reviewed. Information on outcome was obtained by re-examination of the cat or by telephone interview with the owners. All cats had pancreatitis confirmed by histopathological examination of biopsy samples (n=6) or suspected based on gross examination at surgery (n=1). In six cats, a section of 3.5 to five French gauge red rubber catheter and in one cat a section of 22 G intravenous catheter were used as a choledochal stent. Two cats developed re-obstruction of the biliary tract within a week of the original surgery. One cat had confirmed episodes of ascending cholangitis postoperatively. Two cats had chronic intermittent vomiting in the postoperative period. Two cats died during the perioperative period. Five cats survived to discharge, three of which died seven to 24 months postoperatively and two of which remain alive to date. Choledochal stenting is an alternative to biliary diversion for management of feline pancreatitis-associated EHBO in select cases. However, there may be greater morbidity with this technique in cats compared with dogs.

IMAGING DIAGNOSIS—EXTRAHEPATIC BILIARY TRACT OBSTRUCTION SECONDARY TO A DUODENAL FOREIGN BODY IN A CAT

A 13-month-old, neutered female domestic shorthaired cat was evaluated for vomiting, anorexia, and lethargy. The cat was icteric and hyperbilirubinemic. Radiographically a partially radiolucent proximal duodenal foreign body was suspected. Ultrasonographically, there was a foreign body at the level of the duodenal papilla and dilation of the common bile duct and cystic duct; a diagnosis of extrahepatic biliary tract obstruction secondary to a duodenal foreign body was made. Sonographic findings were confirmed at surgery and a duodenal foreign body was removed. This information defines duodenal foreign body as a cause of extrahepatic biliary obstruction in cats.

Multiple myeloma of the liver presenting as non-obstructive jaundice

Dear Editor, Multiple myeloma (MM) involves, mainly but not exclusively, the bone marrow. It is occasionally associated with jaundice. The underlying process may be a myeloma infiltration of the head of the pancreas or hepatic amyloid deposition or extra-hepatic biliary obstruction due to an abdominal plasmacytoma. A rare case of myeloma manifested by jaundice after hepatic myeloma infiltration is reported. A 55-year-old man was referred to our hospital because of weakness, weight loss and jaundice. Physical examination showed somnolence, jaundice and hepatomegaly 10 cm below the costal margin. Cardiovascular and respiratory examinations were normal. Results of the blood test performed on admission were as follows: calcium 3.62 mmol/l, bilirubin 203 μmol/l, alkaline phosphatase 373 IU/l (normal 100–280 UI/l), γ-glutamyltransferase 888 IU/l, lactate dehydrogenase (LDH) 727 IU/l (normal 5–270 IU/l), aspartate aminotransferase (SGOT) 145 IU/l, alanine aminotransferase (SGOT) 136 IU/l, creatinine 1395 μmol/l, haemoglobin 7.6 g/dl, white cell count 8.9× 10/l, platelets 82×10/l, prothrombin index 46% and Creactive protein 40 mg/l. Serum and urine protein studies revealed an M-component Lambda. Serological tests were negative for hepatitis B and C viruses. Blood, stool and urine cultures did not reveal any growth. A bone marrow aspirate was performed, showing 46% of atypical plasma cells with prominent nucleoli (Fig. 1). Residual normal haemopoeitic cells were markedly reduced in number. There was no evidence of lytic lesions on X-ray films. However, abdominal ultrasound scan showed hepatomegaly and ascitis. Neither biliary dilatation nor tumor nodules were seen by abdominal computerized axial tomography (Fig. 2). A liver biopsy was performed and showed dilated sinuses containing plasma cells, plasmablasts and extramedullary haemopoeitic cells. Myeloma cells also infiltrated portal tracts (Fig. 3). There was no evidence of amyloid deposition in the liver biopsy. A diagnosis of MM with liver involvement was made. The patient was treated with Dexamethasone. But unfortunately, his condition deteriorated with the onset of renal failure. He died a few days later. Extraosseous manifestations are found in less than 5% of patients with MM. Elevation of the LDH level suggest the presence of occult extraosseous disease and predict a poor prognosis [1, 2]. In our patient, the serum LDH level was very high. Myeloma causing jaundice has occasionally been reported in literature. However, all cases reported to date have been due to hepatic amyloid deposition or extrahepatic biliary tract obstruction. As far as we know, only two cases of liver dysfunction due to plasma-cell infiltration have been confirmed by biopsy [3, 4]. Liver involvement in MM is uncommon. It is frequently found at autopsy, but it is clinically manifest in a few patients. Signs of liver dysfunction are not part of the Ann Hematol (2007) 86:529–530 DOI 10.1007/s00277-007-0267-9

Cholecystoenterostomy for treatment of extrahepatic biliary tract obstruction in cats: 22 cases (1994–2003)

To identify factors associated with outcome in cats with extrahepatic biliary tract obstruction (EHBTO) that undergo biliary diversion surgery. Retrospective case series. 22 cats. Medical records of cats with surgically confirmed EHBTO that underwent cholecystoenterostomy were reviewed. Clinical signs and physical examination findings included vomiting, anorexia, icterus, lethargy, weakness, and weight loss. Common clinicopathologic abnormalities included high serum hepatic enzyme activities and serum bilirubin concentration. Abdominal ultrasonography was performed in 21 cats, and all 21 had findings consistent with EHBTO. Eleven of 15 cats in which blood pressure was monitored had intraoperative hypotension. Eighteen cats had anemia following surgery, and 14 cats had persistent hypotension. Extrahepatic biliary tract obstruction was a result of neoplasia in 9 cats and chronic inflammatory disease in 13. Fourteen cats survived long enough to be discharged from the hospital, but only 6 survived > 6 months after surgery, all of which had chronic inflammatory disease. Median survival time for cats with neoplasia (14 days) was significantly shorter than that for cats with inflammatory disease (255 days). No other variable was associated with outcome. Results suggest that cats with EHBTO secondary to neoplasia have a poorer prognosis than cats with EHBTO secondary to chronic inflammatory disease. However, the overall prognosis for cats with EHBTO undergoing cholecystoenterostomy must be considered guarded to poor, and the incidence of perioperative complications is high.

Therapeutic percutaneous ultrasound-guided cholecystocentesis in three dogs with extrahepatic biliary obstruction and pancreatitis

Three dogs were examined because of acute pancreatitis. In all 3, distension of the gallbladder was seen ultrasonographically, and extrahepatic biliary tract obstruction (EHBO) was diagnosed on the basis of ultrasonographic findings and serum biochemical abnormalities (i.e., high serum bilirubin and cholesterol concentrations and increased hepatic enzyme activities). In all 3 dogs, percutaneous ultrasound-guided cholecystocentesis (PUCC) was used to decompress the gallbladder, with cholecystocentesis performed multiple times in 1 dog. Serum bilirubin concentration was substantially decreased following the procedure in all 3 dogs. Two of the 3 dogs did not require surgery to resolve the obstruction. In the third dog, an exploratory laparotomy was performed because of concerns about development of abdominal effusion following the procedure. Bile staining of the mesenteric fat was seen during the laparotomy, but no defect in the gallbladder wall could be identified. In most dogs with EHBO secondary to pancreatitis, the obstruction resolves spontaneously as the acute pancreatitis improves so that surgery is not required. In those few dogs in which EHBO does not resolve or in which EHBO results in complications, therapeutic PUCC may be useful in relieving gallbladder distension.

Common bile duct obstruction due to a duodenal gastrinoma in a dog

In dogs gastrinomas are rare endocrine neoplasms that have always been reported to arise from the pancreas. We report here what we believe to be the first case of a duodenal gastrinoma in a dog. A nine-year-old, male, Pekinese dog was presented with a three-day history of anorexia, vomiting and mucous diarrhoea. Clinical examination and laboratory findings suggested the presence of a severe hepatobiliary disorder. Abdominal ultrasonography showed a diffuse increase in echogenicity of the liver, with severe gallbladder dilation and marked dilation of the cystic duct, common bile duct and extrahepatic bile ducts. Based on these findings, an extrahepatic biliary tract obstruction (EBTO) of unknown cause was suspected. At laparotomy, the gallbladder and the extrahepatic bile ducts appeared severely dilated. The gallbladder was tense and could not be compressed suggesting an outflow obstruction. The duodenum at the level of the common duct orifice appeared slightly thickened and severely hardened for a length of 1 cm. Biopsies from the duodenum and liver were obtained and a cholecystoduodenostomy was performed. The duodenal biopsy revealed severe fibrosis of the submucosa and a infiltrate of small pockets and cords of round to polygonal cells with granular cytoplasm. Based on this appearance the differential diagnoses included neuroendocrine tumours and poorly differentiated carcinoma. Despite surgery and supportive therapy the dog continued to be anorexic and to vomit 3–6 times daily. After euthanasia and necropsy, histopathology showed the presence of a neuroendocrine neoplasia involving the duodenal wall with focal invasion of the adjacent pancreas and small liver metastases. On immunohistochemistry, the cytoplasm of approximately 90% of neoplastic cells intensely expressed neuron specific enolase and gastrin. These findings were consistent with a diagnosis of gastrinoma.

Extrahepatic biliary tract obstruction: a retrospective study of 45 cases (1983-1993).

The medical records of 41 dogs and four cats with either surgical or postmortem confirmation of extrahepatic biliary tract obstruction were reviewed. Clinical signs of icterus, vomiting, anorexia, or a combination of these signs were exhibited by 100% of cases. Elevated serum bilirubin was documented in 37 of 41 dogs and two of four cats (86.6%). The predominant, underlying, pathological process was extraluminal obstruction of the biliary tract due to pancreatitis (19 of 45 cases; 42.2%) or neoplasia (11 of 45 cases; 24.4%). Biliary tract surgery was performed in 29 cases, of which 12 (41.3%) recovered. Animals diagnosed with extrahepatic biliary tract obstruction had a relatively good long-term prognosis, provided they were not compromised substantially due to severe necrotizing pancreatitis or neoplasia.