Narrowing Of Common Bile Duct Research Articles

HPB P44 Case Report: Retrograde transhepatic duodenal and antegrade common bile duct stenting in malignant duodenal stricture

Abstract Background Duodenal adenocarcinoma is a rare and aggressive malignancy, that unfortunately often present late meaning diagnosis can be delayed and commonly have no curative surgical options available. Patients with non resectable disease typically have a life expectancy from 2-8 months. In these palliative patients, antegrade stenting of the malignant stricture can effectively relieve symptoms of gastric outlet obstruction. We present retrograde transhepatic duodenal stenting in a patient where antegrade stenting had failed. Methods A 68 year old woman presented with abdominal pain, vomiting and weight loss, was found to have gastric outlet obstruction on imaging and subsequently diagnosed with D1 duodenal adenocarcinoma. Multiple attempts at dilatation had failed and one failed attempt at antegrade stenting to relieve their symptoms. A novel technique of retrograde transhepatic stenting of duodenal stricture and antegrade common bile duct (CBD) was then successfully performed with no post procedure complications. Not only did this help alleviate the patients’ symptoms but allowed subsequent antegrade passage of a D3 stent from a subsequent obstruction. Results Retrograde transhepatic duodenal stenting was carried out under general anesthesia with a right percutaneous puncture to pass a guide wire into the intrahepatic ducts, then the CBD narrowing followed by the duodenal stricture. The duodenal stricture was then stented followed by the CBD stricture and a drain left in the common hepatic duct. Conclusions Although duodenal adenocarcinoma is rare, it should be considered in all patients with suspected gastric outlet obstruction. A multidisciplinary team approach is necessary in managing patients with duodenal strictures. Retrograde transhepatic duodenal should be considered in palliative patients when antegrade stenting fails.

Diagnosis of Pancreatic Cancer: Can Biopsy Misguide?

Pancreatic cancer remains the second leading cause of cancer related mortality in United States with 48,960 new cases and 40,560 deaths in 2015, with a 5 year survival rate of 7.2%. Due to its retroperitoneal location and insidious course, diagnosis of pancreatic cancer remains elusive. Case Presentation: 76 y/o male with past medical history of hypertension, diabetes and hypothyroidism presented with decreased appetite, 60 pound weight loss, fatigue and pale white stools for a year. Laboratory workup revealed AST and ALT ˜ 200 IU/L, ALP > 1200 IU/L, CEA - 9.9 ng/mL, CA-125 of 81.6 U/mL and CA 19-9 of 12131 U/mL. CT abdomen showed extrahepatic and intrahepatic ductal dilatation, narrowing of common bile duct, soft tissue density in the pancreatic head. (figure 1). EUS revealed a 3x2 cm heterogenous mass in pancreatic head encasing bile duct. FNA of the mass was suggestive of benign cellular elements. Repeat EUS-FNA of the mass was also negative for malignancy. During ERCP, sphincterotomy was performed with multiple biopsies of papilla, which were also negative for malignancy. PET scan was also negative for uptake anywhere (figure 2) Due to multiple co-morbidities he was managed supportively and external biliary drain was placed. Autopsy revealed poorly differentiated pancreatic cystadenocarcinoma with signet ring cells and mucinous infiltration involving pancreatic head and body. (figure 3).Figure 1Figure 2Figure 3Discussion: Algorithm for imaging diagnosis of pancreatic carcinoma includes a multi-detector computed tomography (MDCT), MRCP, or fine-needle aspiration using EUS. MDCT has >96% sensitivity for predicting the resectability of pancreatic cancer, however misses small metastases. EUS produces high resolution images of the pancreas and is useful for tumours < 3 cm. EUS-guided FNA is > 90% sensitive in detecting pancreatic malignancy. In our case despite two EUS- FNA attempts, we were unable to get a tissue diagnosis, which highlights potential fallacies. The necessity of obtaining a cytological or tissue diagnosis of pancreatic cancer prior to surgery remains controversial. However in unresectable cases and where palliation is to be considered, pathological proof of malignancy is required for determining neo-adjuvant chemotherapy. This case highlights the fact that despite many advances we still have long strides to make in techniques for diagnosis of pancreatic cancer, to help institute timely management.

A computational extensional rheology study of two biofluid systems

The main focus of the present computational modelling work is to determine the extensional rheological response of some model biofluids, with a view to ultimately aiding experimentally based analyses and clinical practice. This is accomplished in the present study through model extensional flows and rheological investigation, addressing filament stretching and contraction flows, and upon which significant advances are presented. As such, two biofluid flow systems within the human body are of current interest: (i) respiratory disorders and sputum in the lung airways (associated with filament stretching), where stretchiness of mucus sputum in situ is vital, with clinical focus on chronic obstructive pulmonary disease (COPD/sputum); and (ii) bile flow in the biliary system (contraction flow), with clinical focus on disorders of primary sclerosis cholangitis and common bile duct narrowing. Both sputum and bile biofluid systems are represented through kinetic theory rheological fluid modelling, with capability to represent material structure entanglement, branching and anisotropy. This is practically achieved by appealing to the class of pom-pom differential constitutive models, extracted from polymer melt physics and deployed here through a single extended pom-pom (SXPP) approximation. This class of models is sufficiently rich to enable description of both network structure and rheological properties, exhibiting viscoelastic response (memory), with strain-hardening/softening and shear-thinning properties.

Clinics in diagnostic imaging (145)

A 63-year-old man presented with painless jaundice, loss of appetite and significant weight loss. Cross-sectional imaging showed a diffusely enlarged pancreas, with no significant fat stranding and a hypodense rim on computed tomography, which appeared hypointense on T2-weighted magnetic resonance imaging. There was a narrowed pancreatic duct and features of common bile duct narrowing in the region of the pancreatic head. However, there was no obvious mass seen in the pancreatic head region. These features were classical of autoimmune pancreatitis with diffuse involvement of the gland. Laboratory investigation showed abnormal liver function and the classical sign of raised immunoglobulin G class 4 antibodies. The patient showed dramatic response to high-dose steroids, with resolution of both the laboratory and imaging abnormalities within one month. We discuss the classical imaging features of Type 1 autoimmune pancreatitis, an uncommon condition that needs to be differentiated from pancreatic malignancy.

Sphincterotome stricturoplasty for long ampullary stenoses and benign biliary strictures (with video)

Long ampullary stenoses and fibrotic distal biliary strictures are not infrequently encountered during endoscopic retrograde cholangiopancreatography (ERCP). Instead of balloon dilation and stenting, we propose that these strictures can be managed with sphincterotome stricturoplasty (SS) during the initial ERCP. To report our clinical experience with SS for benign distal biliary strictures. Review on prospectively collected data. All (consecutive) patients who underwent ERCP and SS performed by the authors in a 12-month period. Long ampullary stenosis and/or distal biliary stricture is defined as significant narrowing of CBD from the level of duodenal wall into the common bile duct (CBD) after initial sphincterotomy. The upstream CBD is dilated. Despite adequate ES, contrast drainage is poor due to the downstream stricture. SS was performed using the same sphincterotome in slightly bowed position under endoscopic and fluoroscopic guidance. The cutting wire was placed parallel to the superior border within the stricture and incising the stenosis. In cases of relatively long strictures, during initial SS the majority of the cutting wire was inside the biliary opening. This differs from ES, where about one-third to one-half of the length of cutting wire is outside the ampulla. Clinical data, hospital course, procedure-related complication rates, and outcomes were prospectively collected in a database. During the study period, 308 ERCPs were performed. Benign and short (≤15 mm in length) distal biliary strictures were observed in 25 patients. Mean ± SD stricture length was 7.4 ± 3.0 mm. The presumed etiologies for these strictures were choledocholithiasis (n = 22) and postsphincterotomy stenosis (n = 3). There was no perforation, post-ERCP pancreatitis, postsphincterotomy bleeding, or cholangitis. To date, none of these patients who had SS have needed follow-up ERCP. Single-operator experience, limited follow-up period. Compared with balloon stricturoplasty ± biliary stenting, SS is a simple and cost-effective alternative option in managing long ampullary stenosis and/or distal fibrotic biliary stricture during the initial ERCP.

Autoimmune pancreatitis: imaging findings on contrast-enhanced MR, MRCP and dynamic secretin-enhanced MRCP

This study retrospectively determined magnetic resonance (MR), MR cholangiopancreatography (MRCP) and secretin-MRCP findings in patients with autoimmune pancreatitis (AIP). The MR examinations of 28 patients with histopathologically proven AIP were reviewed. In 14 cases, secretin-enhanced MRCP was performed. The observers evaluated pancreatic parenchymal enlargement, signal intensity abnormalities, enhancement, vascular involvement, bile-duct diameter and main pancreatic duct (MPD) narrowing (diffuse/focal/segmental). After secretin administration, the presence of the "duct-penetrating" sign was evaluated. MR imaging showed diffuse pancreatic enlargement in 8/28(29%) cases, focal pancreatic enlargement in 16/28 (57%) cases and no enlargement in 4/28 (14%) cases. The alteration of pancreatic signal intensity was diffuse in 8/28 (29%) cases (eight diffuse AIP) and focal in 20/28 (71%) cases (20 focal AIP). Delayed pancreatic enhancement was present in all AIP, with peripheral rim of enhancement in 8/28 (29%) AIP (1/8 diffuse, 7/20 focal); vascular encasement was present in 7/28 (25%) AIP (1/8 diffuse, 6/20 focal); distal common bile duct narrowing was present in 12/28(43%) AIP (5/8 diffuse, 7/20 focal). MRCP showed MPD narrowing in 17/28 (61%) AIP (4/8 diffuse, 15/20 focal), MPD dilation in 8/28(29%) AIP (3/8 diffuse, 5/20 focal) and normal MPD in 1/8 diffuse AIP. Secretin-MRCP showed the duct-penetrating sign in 6/14(43%) AIP (one diffuse AIP with MPD segmental narrowing, five focal AIP with MPD focal narrowing), demonstrating integrity of the MPD. Delayed enhancement and MPD stenosis are suggestive for AIP on MR and MRCP imaging. Secretin-enhanced MRCP is a problem-solving tool in the differential diagnosis between focal AIP and ductal adenocarcinoma.

Autoimmune Pancreatitis: Disease Evolution, Staging, Response Assessment, and CT Features That Predict Response to Corticosteroid Therapy

To evaluate the evolution of morphologic features of autoimmune pancreatitis (AIP) at computed tomography (CT) and to identify imaging features that can predict AIP response to corticosteroid therapy (CST). This HIPAA-compliant retrospective study had institutional review board approval. From among a cohort of 63 patients with AIP, 15 patients (12 men, three women; mean age, 64.7 years; age range, 30-84 years) who underwent sequential CT examinations before treatment were included to assess the evolution of disease by reviewing pancreatic, peripancreatic, and ductal changes. Of these patients, 13 received CST and underwent posttreatment CT; these CT studies were evaluated to determine if there were imaging features that could predict response to CST. The disease evolved from changes of diffuse (14 of 15 patients) or focal (one of 15 patients) parenchymal swelling, peripancreatic stranding (10 of 15 patients), "halo" (nine of 15 patients), pancreatic duct changes (15 of 15 patients), and distal common bile duct narrowing (12 of 15 patients) to either resolution or development of ductal strictures and/or focal masslike swelling. In 13 patients treated with CST, favorable response to treatment was seen in those with diffuse pancreatic and peripancreatic changes. Suboptimal response was seen in patients with ductal stricture formation (two of 13 patients) and in those in whom focal masslike swellings persisted after resolution of diffuse changes (seven of 13 patients). CT features like diffuse swelling and halo respond favorably to CST and likely reflect an early inflammatory phase, whereas features like ductal strictures and focal masslike swelling are predictive of a suboptimal response and symbolize a late stage with predominance of fibrosis.

Computed tomography evaluation of high-density bile in the gallbladder

On computed tomograms obtained during a seven-year period, 27 patients were found to have high-density bile in the gallbladder. Serial computed tomography (CT) examinations showed that gradual narrowing of common bile duct is a causative factor. This has not been reported previously. The density of the bile in the gallbladder of patients with such obstruction was almost equal to that of normal liver on CT. In some of the patients in whom obstruction of the cystic duct was the factor of high-density bile and continued for a long time, the density of the bile decreased and hydrops developed.