Intrahepatic Biliary Dilatation Research Articles

Clinical Conundrum: An Inflammatory AAA…A Cautionary Tale

Introduction: Inflammatory AAA account for 5–10% of all AAA. Although the pathogenesis of inflammatory AAA appears to involve an immune response localized to the vessel wall, the aetiology of the inflammatory reaction is unknown. Chronic periaortitis is a spectrum of diseases including inflammatory AAA. In most cases chronic periaortitis is idiopathic; other causes are drugs, retroperitoneal injury, infection and malignancy. Case Description: A previously fit and active 66yo man was admitted under medics with blurring of vision and a suspected TIA. During admission he c/o left flank pain with CT showing a 4.3cm inflammatory AAA, left hydronephrosis and right ureteric stone. He required bilateral JJ stents and percutaneous nephrostomy due to persistent left hydronephrosis. Autoimmune screen and temporal artery biopsy were negative. Subsequently he developed bilateral leg swelling and duplex scan showed DVT. Then he developed RUQ pain and obstructive jaundice. Investigations showed gall stones, intrahepatic biliary dilatation, and subsequently CBD dilatation. Initially Unsuccessful, subsequent ERCP and PTC relieved the obstruction but resulted in AKI secondary to CIN and sepsis. Tumour markers were elevated with CA19.9 of 2779. The patient was transferred to ICU and developed multi organ failure and unfortunately passed away. PM revealed a very rare case of signet ring carcinoma of the CBD. Discussion: Causes of inflammatory AAA are multifactorial. This case highlights the need for caution before repair, as a rapidly progressive and aggressive disease course may indicate a malignant aetiology.

Successful Diagnosis and Treatment of Biliary Cast Syndrome after Orthotopic Liver Transplantation by Percutaneous Transhepatic Choledochoscopy: A Case Report

Biliary cast syndrome (BCS) is an unusual complication of orthotopic liver transplantation (OLT). BCS is characterized by multiple intrahepatic biliary strictures, ductal dilatation, intrahepatic abscesses, and biliary anastomotic leakage. The symptoms of BCS usually include high fever, jaundice and cholestatic liver enzyme elevation; similar to the symptoms observed in some patients with intrahepatic bile duct stones. The etiology of cast development is not fully known, and its management is difficult. Limited success using endoscopic retrograde cholangiopancreatography (ERCP) or open exploration to clear casts has been reported, and failure usually results in retransplantation. We describe a diabetic man who developed a BC after deceased donor liver transplantation. Percutaneous transhepatic biliary cholangiography was performed and revealed a filling defect in both the right and left intrahepatic systems, extending down to the anastomosis. Percutaneous transhepatic choledochoscopy proved that it was consistent with BCs, and the casts were removed by stone retrieval basket, foreign body pliers, and adsorber.

Biliary complications of arterial chemoembolization of hepatocellular carcinoma.

Transarterial chemoembolization (TACE) is the most frequently used palliative therapy for unresectable hepatocellular carcinoma (HCC). It is a safe and effective procedure with few major and minor complications. Rarely, biliary complications are also encountered following TACE. The goal of our study was to investigate the incidence and the presentation of biliary complications following TACE in patients with HCC. In this retrospective study, data of patients with HCC who underwent TACE between June 2002 to December 2014 were obtained from the records. Their detailed information about the procedure of TACE, diagnosis of biliary complications and subsequent management details were reviewed. One hundred and sixty-eight patients with HCC underwent 305 procedures of TACE. Of these, biliary complications of various severities developed in 6 (3.6%) patients leading to an incidence of 1.9% (6/305). Minimal intrahepatic biliary dilatation (IHBD) occurred in three, biliary stricture in one and intrahepatic biloma in two patients. Supportive management was undertaken for IHBD patients while percutaneous aspiration and naso-biliary drainage was performed for the infected bilomas. Biliary complications following TACE are infrequent. Diagnosis should be suspected clinically and confirmed with imaging. Treatment depends on the severity. Enforcing specific measures can minimize its frequency.

Role of endoscopic retrograde cholangiography in ruptured hepatic hydatid cyst.

To report endoscopic retrograde cholangiopancreatography (ERCP) findings of intrabiliary hydatid cyst rupture. A retrospective study of cases with intrabiliary rupture of hydatid cyst was conducted. A total of 4 cases (all female with a mean age of 32 years) were included. ERCP and ultrasound data were evaluated. Assessment involved number, location, size, internal and wall characteristics of cyst; intrahepatic biliary radicle dilatation (IHBRD); common bile duct (CBD) dilatation and evidence of extrabiliary rupture on ultrasound. ERCP evaluation included IHBRD, CBD dilatation, communication between cysts and intrahepatic biliary radicles (IHBR) and filling defects within the IHBR and CBD. Treatment details were also obtained. A total of 5 cysts were evaluated in 4 patients. Left lobe cysts were most common (n=4). Segment II/III were the most commonly affected segments (n=3). Cyst outline was smooth and cystobiliary communication noted in all cases. Deformation of cyst wall was noted in 2 cases. Isolated (left or right) IHBRD lateralised to the side of the cyst was most common (n=4). CBD dilatation was seen in all cases with a mean calibre of 1.4 cm. Concomitant extrabiliary rupture was seen in 3 cases. Endoscopic management was done in all cases without complications. Three patients underwent surgical excision after a mean period of 8 weeks following ERCP. Isolated IHBRD lateralized to the side of hydatid cyst with CBD dilatation is the commonest ERCP finding of intrabiliary rupture of hydatid cyst.

Hepatic Artery Mycotic Aneurysm and Microabscesses: A Rare Complication of Infective Endocarditis with Classical Quincke’s Symptom

Hepatic artery branch mycotic aneurysm causing intrahepatic biliary dilatation and associated with hepatic micro abscesses is a rare complication of infective endocarditis and patient presenting with classical Quincke’s symptoms has not been reported in literature so far. We report a case of 38 years old woman who presented with epigastric pain and obstructive jaundice. She has recently been diagnosed to have infective endocarditis. Hepatic artery pseudoaneurysm causing moderate intrahepatic biliary dilatation and micro abscesses was reported on contrast enhanced computed tomography (CT) scan and immediately conveyed to primary physician which led to successful selective transcatheter arterial embolization of the aneurysm, leading to early stabilization and recovery of the patient. Case Study Haroon et al.; IJMPCR, 3(3): 80-83, 2015; Article no.IJMPCR.2015.040 81

BILIO-JEJUNOSTOMY STENOSIS AFTER CEPHALIC-DUODENOPANCREATECTOMY IN CHRONIC PANCREATITIS - CASE REPORT

We present the case of patient SC aged 44 years who underwent surgery 5 years prior to thepresentation to our clinic for a tumor in the head of the pancreas, the operation than consisted of acephalic duodenopancretectomy which was followed by a number of complications. On admissionthe patient had abdominal pain in the right flank, giant median postoperative eventration and aexternal ”a la Witzel” biliary drainage tube. Abdominal ultrasound revealed the presence of ainterhepaticodiaphragmatic collection that measured 4.6 / 3 cm. A cholangiography was donewhich showed biliary tract opacification of the left lobe with the full stop of the contrast in thedistal left main hepatic duct without intrahepatic biliary dilatation. Surgery was undertaken undertotal anesthesia – the intraoperative diagnosis consisted of: almost complete stenosis of the biliojejunostomy.After the adhesions were cut, the bilio-jejunostomy was redone using the left hepaticduct in a terminal-lateral anastomosis. The collection was drained and the abdominal defect wascorrected. The patient maintained a favorable external biliary drainage of about 200 ml per day soin the 5-th postoperative day the drainage was clamped without any complications. Conclusions: 1. Duodenopancreatectomy should be reserved for average / high volume surgical centers. 2. During the intervention the steps to achieve the biliary-digestive anastomosis should be respectedthoroughly 3. Fast reoperation may increase the chance of survival of the patient.

Malignant obstructive jaundice in situs inversus: demonstration of precut and biliary drainage

A 68-year-old man with situs inversus was admitted to our hospital with obstructive jaundice. An MRCP revealed intrahepatic biliary dilation with a long segment stricture of the common hepatic duct and abnormal signal within the hepatic parenchyma near the hilum (Fig. 1) . The patient underwent ERCP in the supine position (Video 1, available online at www.giejournal.org). Repeated attempts to cannulate the bile duct were unsuccessful. Initial engagement was possible, but the guidewire could could only be advanced into the pancreatic duct. A pancreatic precut sphincterotomy was performed in the opposite orientation at the 1 o’clock position in an attempt to expose the bile duct. Cannulation of the bile duct was still unsuccessful, so a needle-knife precut was performed in a 1 to 2 o’clock orientation. Cannulation of the bile duct was then achieved, and a biliary sphincterotomy was performed. Cholangiogram confirmed a common hepatic duct stricture with proximal upstream dilation. Brushings of the biliary stricture were performed over a guidewire. A 5F × 15 cm single pigtail plastic stent was deployed over a guidewire into the pancreatic duct. A 10 × 60 mm fully covered, self-expanding metal stent was deployed across the biliary stricture with successful biliary drainage post-deployment. Pathology from the biliary brushings revealed cholangiocarcinoma. Magnetic resonance angiography showed no vessel involvement and no distant metastases. The patient is currently awaiting surgical resection by the liver transplant surgical team.

CT evaluation of common duct dilation after cholecystectomy and with advancing age.

To evaluate common duct (CD) dilation by computed tomography (CT) in patients with intact gallbladders and diameter change over time in remote and interval cholecystectomy patients, frequency of visualization of the CD, and its relationship to age. This IRB-approved retrospective study evaluated baseline CD diameter, intrahepatic biliary dilation, and interval duct diameter change in patients with CTs ≥ 2 years apart (n = 324), in block-randomized order by two blinded board-certified radiologists. 272 patients were divided into three groups: (1) prior cholecystectomy before the first CT, (2) cholecystectomy between the first and last CTs, and (3) no cholecystectomy. A subset of 191 nonoperated patients was evaluated for age-related dilation. Group 1 ducts were significantly larger than the other groups at both baseline and follow-up CTs (p < 0.001). Group 2 showed a greater increase in duct size than the other groups at follow-up (p < 0.001). The CD was measurable in 89% of the CT studies. In nonoperated patients, there was a statistically significant correlation between CD size and increasing age (p < 0.001), although the CD size remained within normal size limits. Remote cholecystectomy patients have larger CD diameters than the nonoperated and interval cholecystectomy groups. Greater increase in ductal diameter occurred between studies in the interval cholecystectomy patients, suggesting that dilation occurs after cholecystectomy. Also, the CD dilates slightly with age in nonoperated patients.

Obstructive Jaundice From Metastatic Prostate Cancer

Introduction: Prostate cancer commonly presents with bone metastases and lymphadenopathy, but development of obstructive jaundice is extremely rare especially without metastases to liver parenchyma. Case Report: A 48-year-old African American male with a recent diagnosis of metastatic prostate cancer presented with elevated liver enzymes and painless jaundice. The patient had metastatic spread to the bone and lungs, and extensive peripancreatic, portacaval, aortocaval, and common iliac lymphadenopathy. He was currently being treated with bicalutamide and lueprolide. Upon presentation, he described 1 week of increasing jaundice without abdominal pain, fever, nausea, or vomiting. He was afebrile. Aside from generalized jaundice and icteric sclera, no hepatomegaly, asterixis, or petechiae were noted on exam. Labs revealed an elevated aspartate transferase (158 units/L), alanine transferase (372 units/L), alkaline phosphatase (515 mU/mL), total bilirubin (8.2 mg/dL) and direct bilirubin (4.5 mg/dL); all of which were normal 2 months prior. The creatinine, blood count, and coagulation studies were normal. HIV test was negative, as were hepatitis serologies. The patient denied alcohol intake and acetaminophen use. Echogram of the liver showed a mass, consistent with lymphadenopathy, that was previously visualized on computed tomography imaging near the portahepatis and now measured 41 x 50 mm. The mass was causing compression of the common bile duct (CBD) with intrahepatic biliary ductal dilation. Magnetic resonance cholangiopancreatography also showed interval development of moderate intrahepatic and extrahepatic biliary duct dilation with the CBD measuring 2 cm and tapering abruptly in a bird beak configuration, also likely secondary to lymphadenopathy near the pancreatic head. The patient underwent endoscopic retrograde cholangiopancreatography during which mid-proximal extrahepatic bile ducts were noted to be dilated to 2 cm, and a 4-cm long, likely malignant biliary stricture was found at the distal CBD. Sphincterotomy was performed and a metallic biliary stent was placed. Histological examination of specimen was consistent with metastatic prostate cancer. The patient’s liver enzymes returned to normal within 5 weeks. Conclusion: Obstructive jaundice in prostate cancer has been documented due to a metastatic mass surrounding the CBD or infiltrating the head of the pancreas. Cyproterone acetate and flutamide, structurally similar to bicalutamide, have also been associated with cholestatic jaundice. After considering other etiologies, clinicians should consider the possibility of biliary obstruction secondary to widespread lymphadenopathy. Palliative stenting greatly improves quality of life.

A Case of Drug-Induced Cholangitis and Cholestasis From Amoxicillin/Clavulanic Acid and Levofloxacin

Introduction: Drug-induced liver injury (DILI) continues to be an important disease in clinical practice. Amoxicillin/clavulanic acid and levofloxacin are commonly used with a good safety profile. We describe a case of drug-induced cholangitis and cholestasis from amoxicillin/clavulanic acid and levofloxacin. Case Report: An 89-year-old male presented with a 1-day history of jaundice, dark urine, and pale stools. He was treated with 2 10-day courses of amoxicillin/clavulanic acid for a urinary tract infection, followed by a 10-day course of levofloxacin for pneumonia 1 week before presentation. He does not drink alcohol and had no personal or family history of liver disease. Physical exam was significant for jaundice. Laboratory evaluation demonstrated a total bilirubin of 11.1 mg/dL, direct bilirubin of 9.1 mg/dL, alkaline phosphatase of 1001 U/L, gamma-glutamyl-transpeptidase of 793 U/L, alanine aminotransferase (ALT) of 343 U/L, aspartate aminotransferase (AST) of 427 U/L, INR of 1.03, and albumin of 3.3 g/dL. Magnetic resonance cholangiopancreatography (MRCP) was negative for extrahepatic and intrahepatic biliary dilation. A liver biopsy revealed inflammation infiltrating the bile ducts and hepatocanalicular cholestasis consistent with drug-induced cholangitis and cholestasis. His liver function tests started to improve gradually within days after stopping levofloxacin. Discussion: DILI continues to be an important disease in clinical practice. Its diagnosis is mainly based on the exclusion of alternative causes of liver damage. Amoxicillin/clavulanic acid is a combination of amoxicillin and the β-lactamase inhibitor clavulanic acid. The latter component seems to be the prime offender for the liver injury. Amoxicillin/clavulanic acid has been reported to cause drug-induced intrahepatic cholestasis due to a metabolic idiosyncrasy or a hypersensitivity mechanism. It has also been reported to cause ductopenia. Levofloxacin is a fluoroquinolone commonly used to treat respiratory infections. Fluoroquinolones have been associated with drug-induced liver injury, ranging from a brief rise in transaminase level or cholestatic jaundice to severe hepatotoxicity. Levofloxacin has been associated with acute hepatitis, fulminant hepatic failure, and death. The mechanism of levofloxacin-induced hepatotoxicity is not known. Treatment for DILI is mainly the cessation of the offending drug, which may lead to recovery in liver enzyme abnormalities. We believe that our patient suffered from amoxicillin/clavulanic acid and levofloxacin-induced cholestasis and cholangitis. Clinicians should be familiar with the potential hepatoxicities from amoxicillin/clavulanic acid and levofloxacin.

A Unique Case of Radiation-Induced Cardiac, Biliary, and Duodenal Strictures in a Patient With Prior Hodgkin’s Lymphoma

Introduction: A 48-year-old man with a history significant for mantle radiation and chemotherapy completed in 1989 for Hodgkin’s lymphoma and a more recent history of cardiac stenting secondary to radiationinduced cardiac stenosis presented to Albany Medical Center with a 1.5-week history of jaundice. MRI showed a diffusely dilated bile duct to the level of the ampulla with intrahepatic biliary dilation. He underwent EUS/ERCP, which showed the upper third of the main bile duct to contain a single high-grade localized stenosis 30 mm in length with markedly dilated left and right hepatic ducts and dilation of all intrahepatic branches. An area of duodenal stenosis was also noted at the time of the endoscopy, requiring balloon dilation prior to completion of the ERCP. Cytologic brushings of the stricture were negative. In subsequent months, the patient had multiple repeat ERCPs with metal stent placement and exchanges. The patient also continued to have a persistent duodenal stenosis requiring balloon dilation prior to each ERCP. Eventually placement of bilateral plastic biliary stents was performed due to recurrent episodes of cholangitis and failure after repeated metal stenting. Repeat duct brushings continued to return negative. General surgery was consulted for surgical evaluation of a hepaticojejunostomy for treatment of his recurrent high-grade biliary stricture. In the operating room the patient was found to have a significant amount of inflammation and scarring secondary to radiation, involving the right upper quadrant with the duodenum stuck against the porta hepatis along with omentum and colon overlying this. This created a mass-like effect in the porta hepatis and made the possibility of a safe and complete dissection too high risk. A percutaneous transhepatic cholecystostomy tube was placed for long-term management of his biliary stricture. Mantle radiation has long been known to cause delayed complications in the form of cardiac disease and secondary cancers. Our case demonstrates a unique presentation of cardiac, biliary, and GI tract stricturing. This patient presented not only with the common presence of cardiac stenosis and requisite coronary stenting, but was quite distinctive in terms of the resultant involvement of both the biliary system and GI tract, with recurrent biliary stricturing requiring repeated metal stenting and the development of duodenal stenosis requiring repeated balloon dilation. Although radiation-induced biliary and duodenal stenosis has been reported, such a latent presentation from prior mantle radiation is rare in the literature.

Xanthogranulomatous Cholecystitis Mimicking Cholangiocarcinoma

Introduction: Xanthogranulomatous cholecystitis (XGC) is a variant of chronic cholecystitis. It is a benign but locally invasive process that involves the adjacent organs and mimics malignancy often leading to a more radical surgery than needed to treat the condition. Case Report: A 42-year-old otherwise healthy male presented with progressive jaundice and 30-lb weight loss over 1 month. He had no prior history of liver disease, no significant alcohol use, no new medications or supplements. Physical exam was unremarkable except for scleral icterus. Laboratory tests were significant for elevation of aspartate aminotransferase (118 u/L), alanine aminotransferase (265 U/L), alkaline phosphatase (282 U/L), total bilirubin (6.1 U/L), and conjugated bilirubin (4.3 U/L). Abdominal ultrasound showed a 2.7-cm fixed stone in the gallbladder neck and dilation of the common bile duct (CBD) to 1.3 cm with intrahepatic biliary ductal dilatation. An ERCP was performed and revealed a severe stricture at the junction of CBD and common hepatic duct (CHD) with non-visualization of the cystic duct. The biliary stricture was balloon dilated and a plastic biliary stent was placed across the stricture. Mirizzi’s syndrome was suspected and an MRCP was performed, which revealed an enhancing, infiltrative mass-like process near the neck of the gallbladder, proximal CBD, and duodenum. It caused effacement of the CHD, cystic duct, and proximal CBD with intrahepatic duct dilatation. An endoscopic ultrasound was performed revealing a hypoechoic mass around the neck of the gallbladder and proximal common bile duct. The mass involved the muscularis propria layer of the duodenal wall. There was also 1.1-cm enlarged reactive-appearing periportal lymph node. Enodscopic ultrasound-guided final needle aspiration (EUS-FNA) of the mass and lymph node were performed. Bile duct brushings were obtained. FNA from the mass returned chronic inflammation with histiocytes. FNA from the lymph node revealed benign lymphoid tissue. Bile duct brushing showed atypical cells favor reactive and FISH was negative for polysomy. Due to the atypical appearance of the mass, possibility of malignancy and presence of symptoms an exploratory laparotomy was performed. The gallbladder and perihilar nodes were resected and submitted to frozen section that revealed inflammation without cancer. Final pathological examination returned xanthogranulomatous tumor-like inflammation and fibrosis without malignancy. Conclusion: Differentiating XGC from cholangiocarcinoma is a challenge especially when the inflammation involves the CBD and causes obstructive jaundice. However, keeping this differential in mind can help surgical planning and the use of frozen section pathology can limit radical surgery.

Acute Massive Hepatic Enlargement in Sickle Cell Disease

Introduction: Enlargement of the liver is a common condition in clinical practice and has multiple etiologies. Acute massive increase in liver size within a matter of 48 hrs is an unusual event. We report a case of a 25-year-old female patient with sickle cell disease who presented with right upper quadrant abdominal pain, fever, and leukocytosis of 36,000 mm3. A urine analysis suggested UTI and she was treated with antibiotics along with intravenous fluids. On the 2nd hospital day, the hemoglobin dropped to 6.8g/dl from 8.2g/dl on admission. The leukocytosis increased to 45,900 mm3 and the total bilirubin from a baseline of 9.0 mg/dl on admission, rose to 12.7 mg/dl two days later. A CT scan of the abdomen on admission showed a liver of normal size with mild intrahepatic biliary ductal dilatation. Two days later, with persistent right upper quadrant discomfort, worsening leukocytosis, and the rapid drop in hemoglobin, the patient underwent a repeat CT scan followed by MRI of the abdomen. In 2 days, the liver size had drastically increased from 17.5 cm to 20.5 cm in vertical length along the mid clavicular line. An infiltrative or cobble stone type pattern had appeared in the liver parenchyma. There was no intrahepatic or common duct dilatation. The hepatic and portal veins were patent. On subsequent vascular duplex study of the inferior vena cava (IVC), the hepatic and portal veins showed no evidence of thrombosis. Because of the patient’s deteriorating status, exchange transfusion was performed, following which, the liver function tests improved and liver size clinically diminished. This intriguing case illustrates the rare syndrome of hepatic sequestration in sickle cell disease. Our patient had an acute increase in liver size, which was not due to hepatic or portal vein thrombosis; nor was it due to cholestasis. Sickle cell disease may result in sequestration of red blood cells in the spleen or lungs. On occasion, the liver is the site of RBC sequestration. In addition to pain and a falling hematocrit, liver size increases rapidly. This sequence of events in the liver may be missed unless liver size is regularly measured. When hepatic sequestration occurs, prognosis is grave and exchange transfusion should be considered as a potentially life saving strategy. Our patient with sickle cell disease had a dramatic picture of an acutely enlarging liver, which with appropriate treatment rapidly returned to normal size.

A Case of IgG4-Negative Sclerosing Cholangitis and Autoimmune Pancreatitis Responsive to Steroids

Introduction: IgG4-related disease (IRD) is a multi-organ fibroinflammatory syndrome characterized by typical histopathology, tissue infiltration with IgG4-positive cells, and elevation of serum IgG4. Manifestations of IgG4-associated systemic disease include IgG4-associated cholangitis (IAC) and autoimmune pancreatitis (AIP, type 1). Various diagnostic criteria have been suggested, combining the serologic measurement of IgG4 levels with characteristic clinical, radiologic, and histologic findings. Herein, we present a case that defied classification and thus presented a substantial diagnostic and therapeutic dilemma. Case Report: A 70-year-old male presented to the emergency department with complaints of pruritis, anorexia, weight loss, and painless jaundice. A CT of the abdomen was notable for diffuse intrahepatic biliary ductal dilatation with multiple abrupt annular strictures. MRCP revealed a 2.9-cm posterior pancreatic head mass and thus initial diagnostic concern was for pancreatic malignancy. ERCP with biliary duct dilation and stent placement was performed and a biopsy showed atypical biliary epithelium with inflammation but no evidence of malignancy. An EUS was performed and FNA specimen obtained, with histology demonstrating nonspecific chronic inflammation without IgG4 positivity by immunoperoxidase staining. Total serum IgG levels were elevated, but the IgG4 subset was within normal limits (28.8). The CA 19-9 level was 228. After excluding malignancy, the patient was empirically treated with oral prednisone 40 mg daily for 4 weeks and tapered gradually. His symptoms abated and radiologic findings of biliary duct dilatation and stricturing, as well as the pancreatic mass, resolved. At 1-year follow-up, he has been weaned off steroids and is symptom free. Discussion: IRD is an under-recognized protean disorder, mimicking many systemic conditions. Our case demonstrates the gap in current diagnostic classification of IRD. AIP and IAC should be suspected in patients with unexplained biliary strictures and pancreatic diseases regardless of serum IgG4 levels, as this finding is present in only 50-90% of patients. Evaluation for possible pancreatic and biliary malignancies should take primary precedence. However, when malignancy is excluded and features of AIP are present despite negative serologic and histologic evaluation, an empiric steroid trial is reasonable and may prove diagnostic, as AIP is nearly universally steroidresponsive.Figure 1

Proximal Migration of a Biliary Stent into the Peritoneum Through a PTC Catheter Tract

Introduction: Proximal stent migration can cause biliary obstruction and can act as a source for infection and stone formation with the potential for life-threatening complications. Stent removal rarely requires surgical intervention for removal as endoscopic techniques have advanced. We report a case of unusual proximal stent migration into the peritoneum managed surgically. A 77-year-old female with a past medical history of hypertension, diabetes melitus, cholecystectomy, choledocholithiasis status post multiple ERCPs, presented to the ER for jaundice and right upper quadrant abdominal pain. Patient was found to have elevated liver function tests, and MRCP revealed intrahepatic biliary ductal dilatation and unvisualized distal CBD, suggesting either stricture or compression by tumor. ERCP was performed and the guidewire was advanced through the ampulla. The CBD could not be cannulated with balloon catheter or sphincterotomy. ERCP was terminated and patient was referred to IR for PTC with biliary drain. One day later the patient developed sepsis with suspected CBD obstruction and biliary sepsis. She had another ERCP in which the CBD was able to be cannulated with sphincterotomy. Cholangiogram revealed a dilated biliary tree with a distal CBD stricture along the PTC catheter in place. The PTC catheter was removed and a pigtail stent was placed. She continued to have abdominal pain with an abdominal CT showing air within the biliary tree with intrahepatic bile duct dilatation. ERCP was performed again, during which the previously placed CBD stent was not seen and flouroexam showed proximal migration of the stent. At this point, multiple unsuccessful attempts were made to retrieve the migrated stent using balloon catheter, memory basket, rat tooth forceps, and snare. Surgery was consulted for biliary stent removal and biliary drain placement. During the procedure, bile was seen in the subcutaneous area and fascia of the linea alba. The anterior fascia of the rectus abdominus was opened at the level of the peritoneum, where the tip of the biliary stent was removed. A biliary drain was then placed percutaneously via the peripheral left intrahepatic duct. Over the next 5 days, the patient’s liver function tests improved, diet was advanced, and patient was discharged. Stent migration in itself is a rare entity which can cause significant morbidity, and stents that have migrated proximally are usually able to be retrieved on most occasions by endoscopy. Our patient proved to be difficult in that the stent had migrated through a previous placed PTC catheter tract into the peritoneum. This phenomenon has never been described in literature and should make gastroenterologists aware of the possibility and difficulty in retrieving stents that migrate in this nature. Surgical intervention should always be considered in this situation.

Gastroduodenal Signet-Ring Cell Carcinoma Presenting as IgG4-Related Sclerosing Cholangitis: Not Everything That Glitters Is Gold

Introduction: IgG4-related sclerosing cholangitis (IgG4-SC) is a new entity of cholangiopathy and IgG4-related disease, described as dense infiltration of IgG4-positive plasma cells and extensive fibrosis in the bile duct wall. We presented a case of signet-ring cell carcinoma of the duodenum with initial presentation of IgG4-SC. A 75-year-old male presented with gradual-onset painless jaundice and right upper quadrant pain for 3 weeks. He was afebrile, with mild right upper quadrant tenderness, without Murphy’s sign. Labs were pertinent for AST of 142 U/L, ALT of 142 U/L, alkaline phosphatase of 461 U/L, and direct/total bilirubin of 3.5/9.3 mg/dL. MRCP showed intrahepatic biliary dilatation with right hepatic duct strictures and non-visualization of the proximal common hepatic and central common bile ducts, replaced with vague enhancement. Further investigations were significant for negative CA 19-9, CA-125 of 125 U/mL (0-30), and normal gamma immunoglobulin subclasses. EUS showed marked thickening of the extrahepatic bile duct up to the hilum without definite mass lesion. He underwent ERCP for biliary sphincterotomy and biliary stenting. Biopsies of the ampulla and the bile duct showed frequent IgG4-positive plasma cells (30 cells/highpower field). Steroid was initiated for possible IgG4-SC. At 10 days after the index ERCP, he had worsening nausea and vomiting without worsening labs. ERCP for biliary stent exchange showed narrowing of the duodenal bulb and the proximal second portion of the duodenum. Biopsies of the duodenum and the bile duct showed nonspecific inflammatory changes without evidence of malignancy. Over a 4-week follow-up after the index ERCP, he developed worsening clinical gastric outlet obstruction. Repeat ERCP/EUS revealed thickening of the pre-pyloric antrum and proximal duodenum without obvious mass, and diffuse sclerosis of the bile duct, especially the right hepatic duct, and markedly dilated left duct. Duodenal biopsies eventually revealed poorly differentiated signet-ring cell carcinoma. At 2 months, he developed new-onset symptomatic pleural effusion and ascites. Cytology analysis of the fluids showed adenocarcinoma. He died under hospice care at 2 months after initial presentation. IgG4-SC is a new challenging disease that clinicians should consider in the differential diagnosis of cholangiopathy (e.g., cholangiocarcinoma and primary sclerosing cholangitis). This case represents an example of signet-ring cell carcinoma of the stomach and duodenum that presented as IgG4-SC. These could represent separate concurrent disease processes; the latter could result from immune dysregulation secondary to occult malignancy, or represent a nonspecific change.

The road to hell is paved with good intentions

A patient presented with an acute episode of bright red blood in her stool. The incidental liver mass seen in segment 4 was suspected to represent a cholangiocarcinoma due to associated mild intrahepatic biliary ductal dilatation and suspicion for capsular retraction. Pathology confirmed that this lesion represented a sclerosing hemangioma. This case report corroborates prior observations that degenerative changes in hemangiomas—sclerosis, narrowing of vascular channels, thrombosis, infarct, hemorrhage—may produce atypical radiographic findings. Since these atypical radiographic features may suggest a primary or metastatic malignancy, the protean appearance of hemangiomas remains an important consideration in the evaluation of hepatic masses.

Biliary Obstruction From Paraesophageal Hernia

n 83-year-old woman presented with 3 weeks of Apainless jaundice. She reported having some dyspnea after meals for the past 3 months. On examination, bowels sounds were audible from the lower half of her chest. The abdominal examination was unremarkable. Significant laboratory findings included the following: aspartate aminotransferase level, 200 U/L; alanine aminotransferase level, 150 U/L; alkaline phosphatase level, 660 U/L; and serum total bilirubin level, 20 mg/dL. Chest radiography showed loops of intestine in the thoracic cavity, representing enterothorax (Figure A). Computed tomography of the chest and abdomen showed a massive hiatal hernia with protrusion of stomach, small intestine, colon, pancreas, and a portion of common bile duct into the thoracic cavity (Figure B). The gall bladder was distended massively with severe intrahepatic and extrahepatic biliary dilatation (Figure B, red arrow). A partial volvulus of common bile duct was present, with the duct being twisted and running cephalad with acute tapering at the hiatus; thus causing obstructive jaundice (Figure B, green arrow). Figure C (red arrows) shows the diaphragm on both sides with massive hiatal hernia. A percutaneous transhepatic cholangiography was performed for biliary decompression. Figure D shows the cholangiogram with a biliary catheter in place, the common bile duct running superiorly, with an abrupt narrowing at the level of the hiatus in comparison with the computed tomography scan image, and finally ending in the duodenum(arrow; C, commonbile duct; D, duodenum; L, left hepatic duct; R, right hepatic duct; S, stomach). Laparotomy confirmed type IV paraesophageal hernia. Fifty centimeters of small bowel was resected because of signs of strangulation. The hernia sac was removed, and the contents were replaced into the abdominal cavity. The crura were sutured with a mesh, and a Nissen fundoplication was performed. Repeat imaging did not show any narrowing of the common bile duct. Jaundice improved immediately postoperatively. Jaundice caused by biliary obstruction is an extremely rare presentation of a paraesophageal hiatal hernia. It first was reported in 1986. However, only 2 cases have been reported thereafter. A massive paraesophageal hernia involving the intestine eventually may lead to an abnormal cephalad course of common bile duct through diaphragmatic hiatus and may result in extrinsic compression of the bile duct. Percutaneous cholangiography is important to confirm the anatomic position of the bile duct as well as for biliary decompression to prevent cholangitis. Evidence of jaundice warrants early surgical correction of the paraesophageal hernia.

Magnetic resonance imaging cholangiographic evaluation of normal common bile duct size

Background: Regardless of the etiology of biliary diseases, intrahepatic or extrahepatic biliary dilatation is usually observed as a result. To investigate the possible reasons, primarily, we have to determine the dilatation. At this point, the most important question is what is the limit of a normal common bile duct (CBD) size and does it really differ after cholecystectomy? The size of normal CBD has been measured and reported in previous studies by various imaging methods but to our knowledge, it has not been measured by MRI cholangiography before. The aim of this study was, therefore, to determinate the normal diameter of CBD and to compare with post-cholecystectomy patients by MRI cholangiography. Findings: MRI data was acquired for a six month period retrospectively. A total of 104 patients who had undergone MRI cholangiography due to any reason were divided into two groups: with cholecystectomy (31 patients) and without cholecystectomy (73 patients). The mean diameter of normal CBD in those without and with cholecystectomy patients was 4.28 mm and 7.92 mm respectively. Mean of CBD diameters of post-cholecystectomy patients was significantly greater than the control group (p<0.001). Conclusion: In conclusion, the mean diameter of normal CBD shows a significant increase in cholecystectomized patients.

A surgical case of haemothorax

An 83-year-old female presented with a 6-day history of painless jaundice, anorexia, dark urine, steatorrhea and weight loss of 10 kg over the past year. The only past medical history was a monoclonal gammopathy of unknown significance. She was a never-smoker and did not drink alcohol. On examination, she was apyrexial and normotensive. She was clinically jaundiced, and had 4 cm non-tender hepatomegaly. Initial blood tests revealed a bilirubin concentration of 166 μmol·L−1 (normal range 0–21 μmol·L−1), alkaline phosphatase of 371 units·L−1 (normal range 30–150 units·L−1) and an alanine transaminase of 145 units·L−1 (normal range 0–40 units·L−1). Her renal function and inflammatory markers were normal. An abdominal ultrasound showed intra-hepatic biliary dilatation, suggesting obstruction in the lower common bile duct. She went on to have a computed tomography (CT) scan of her abdomen, which showed a small amount of ascites, peritoneal nodularity, bile duct dilatation and a mass in the body and tail of the pancreas involving the aorta and left adrenal gland. Several attempts at a percutaneous trans-hepatic cholangiogram (PTC) were made, but the radiologist was unable to cannulate the biliary ducts. A stent was then inserted at endoscopic retrograde cholangiopancreatography (ERCP) and a biopsy of the mass was carried out. 24 h later the patient deteriorated with pyrexias, hypotension and new onset atrial fibrillation with a fast ventricular rate. Her white blood cell count rose to 16.5×109 cells·L−1 from 12.4×109 cells·L−1 and her C-reactive protein to 52 mg·L−1 (normal level less than 5 mg·L−1). Her haemoglobin dropped from 116 g·L−1 to 93 g·L−1. Her kidney and liver function tests also deteriorated and a chest radiograph showed a new right pleural effusion (fig. …