Nondilated Bile Ducts Research Articles

Factors Associated With Difficult Endoscopic Ultrasonography-guided Biliary Drainage.

When endoscopic retrograde cholangiopancreatography-guided biliary drainage is challenging, endoscopic ultrasound-guided biliary drainage (EUS-BD) can be used as an alternate treatment; however, this method requires operator expertise. Therefore, this study aimed to clarify the factors that are associated with a difficult EUS-BD. Patients who successfully underwent EUS-BD were enrolled in this study. The patients were divided into the easy group and difficult group depending on whether the procedural time was more than 60 minutes, which was the cutoff value elicited from past reports. Patient characteristics and procedural factors were compared between the two groups. The factors associated with difficult procedures were also investigated. The patient characteristics were not significantly different between the easy group (n=22) and the difficult group (n=19). The diameter of the punctured bile duct was significantly different between the two groups. In the multivariate analysis, the diameter of the punctured bile duct was the only factor associated with a difficult EUS-BD (odds ratio 0.65, 95% confidence interval 0.46-0.91, P value=0.012). The cutoff value for the diameter of the punctured bile duct in predicting a difficult EUS-BD was 7.0mm (area under the curve: 0.83, sensitivity 84.2%, specificity 86.4%). A nondilated bile duct might be a predictive factor for a difficult EUS-BD. For beginners of EUS-BD, the cutoff value for the punctured bile duct diameter found in this study, 7.0mm, might become a barometer for puncture point selection.

Linear Endoscopic Ultrasound Examination of the Biliary System and Its Clinical Applications

AbstractEndoscopic ultrasound (EUS) examination of the biliary system plays pivotal role in pancreatobiliary studies. EUS offers a safe and noninvasive method of the biliary tract disorder evaluation. Although radial EUS provides a straightforward orientation, practicing biliary system examination with a curvilinear echoendoscope is advisable because of its added therapeutic benefits. Linear EUS may pose challenge in understanding the orientation and tracing nondilated bile duct in the beginning. However, adopting a systematic station-wise approach can help in comprehending the orientation and effectively tracing the entire bile duct. In this review, we have discussed linear EUS examination of the bile duct and gallbladder from various stations and its clinical applications.

Effectiveness of ultrasound-guided percutaneous transhepatic biliary drainage to reduce radiation exposure: A single-center experience.

Percutaneous transhepatic biliary drainage (PTBD) has been an effective treatment to access the biliary tree, especially in case of endoscopically inaccessible biliary tree. In general, PTBD techniques are divided into two methods: fluoroscopy-guided PTBD and ultrasound (US)-guided PTBD. This study aimed to evaluate the effectiveness of US-guided PTBD, focusing on radiation exposure according to intrahepatic duct (IHD) dilatation degree, differences between right- and left-sided approaches and differences between benign and malignant biliary stenosis/obstruction. We evaluated technical success, clinical success, procedural data (the number of liver capsule punctures, procedural time, fluoroscopy time and radiation dose), and procedure-related complications. During the study period, a total of 123 patients with biliary stenosis/obstruction or bile leakage were initially eligible. We excluded 76 patients treated with only ERCP or initially treated with ERCP followed underwent PTBD insertion. Finally, a total of 50 procedures were performed in 47 patients. Of the 47 patients, 8 patients had anatomical alteration due to previous surgery, 6 patients refused ERCP, and 3 patients failed ERCP. For the remaining 30 patients, PTBD was performed on weekend or at night, 11 of whom had poor general condition, 10 patients underwent ERCP 3 to 4 days later after PTBD insertion, 6 patients improved after PTBD insertion without ERCP, 1 patient died, and 1 patient was referred to other hospital. Remaining 1 patient underwent surgery due to Mirizzi syndrome. All procedures were performed by two interventional radiologists. Technical success rate was 100%, clinical success was 94%, and the complication rate was 10%. Fluoroscopy time and the reported radiation dose were significantly lower in patients with dilated bile ducts than in those with non-dilated bile ducts, when biliary puncture under US guidance was performed initially. However, even in patients with non-dilated bile ducts undergoing initial trials of biliary puncture under US guidance, the fluoroscopy time and the reported radiation dose were low, based on current studies. No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures and benign and malignant biliary stenosis/obstruction. Thus, US-guided PTBD was found to be a safe and effective technique that significantly reduced fluoroscopy time and radiation doses.

Risk Factors for Hemorrhagic Adverse Events in Percutaneous Transhepatic Biliary Drainage: A Prospective Multicenter Study

PurposeTo determine risk factors (RFs) for hemorrhagic adverse events (AEs) associated with percutaneous transhepatic biliary drainage (PTBD) and to develop a risk assessment model. Materials and MethodsThis was a multicenter, prospective, case control study between 2015 and 2020. Adults with an indication for PTBD were included. Patients who had undergone recent previous drainage procedures were excluded. Multiple variables were controlled. The exposure variables were the number of capsular punctures and passes (using the same puncture). A multivariate analysis was performed (logistic regression analysis). ResultsA total of 304 patients (mean age, 63 years ± 14 [range, 23–87 years]; female, 53.5%) were included. Hemorrhagic AEs occurred in 13.5% (n = 41) of the patients, and 3.0% (n = 9) of the cases were severe. Univariate analysis showed that the following variables were not associated with hemorrhagic AEs: age, sex, bilirubin and hemoglobin levels, type of pathology, portal hypertension, location of vascular punctures, ascites, nondilated bile duct, intrahepatic tumors, catheter features, blood pressure, antiplatelet drug use, and tract embolization. Multivariate analysis showed that number of punctures (odds ratio [OR], 2.5; P = .055), vascular punctures (OR, 4.1; P = .007), fatty liver or cirrhosis (OR, 3.7; P = .021), and intrahepatic tumor obstruction (Bismuth ≥ 2; OR, 2.4; P = .064) were associated with hemorrhagic AEs. Patients with corrected coagulopathies had fewer hemorrhagic AEs (OR, −5.5; P = .026). The predictability was 88.2%. The area under the curve was 0.56 (95% confidence interval, 0.50–0.61). ConclusionsPreprocedural and intraprocedural RFs were identified in relation to hemorrhage with PTBD. AE risk assessment information may be valuable for prediction and management of hemorrhagic AEs.

Biliary balloon dilator impaction in a non-dilated bile duct with anatomical variations: a case report

BackgroundWhile techniques for extracting large stones from dilated bile ducts are increasing, options for small stones impacted in non-dilated bile ducts are limited.Case presentationWe report the case of an impacted biliary balloon dilator in a choledocholithiasis patient with a non-dilated bile duct and multiple anatomical variations, including low insertion of the cystic duct. After unsuccessful attempts with a stone extraction basket and balloon, a biliary balloon dilator with a sharp catheter tip was advanced into the bile duct. The balloon could not be removed from the bile duct even when deflated. The duodenoscope fell back into the stomach, causing the shaft of the dilator to break near the ampulla. We then removed the broken tip with a snare, which caused the balloon sheath to separate from the shaft and remain in the bile duct. Finally, we removed the sheath with rat-tooth forceps, leading to successful extraction of the stone-and-balloon complex.ConclusionsThe exceedingly rare possibility of balloon impaction should be kept in mind when using biliary balloon dilators in non-dilated bile ducts.

Utility of dedicated bougie dilator for a 0.018-inch guidewire during EUS-guided biliary drainage: A multi-center retrospective cohort study.

During endoscopic ultrasound-guided biliary drainage (EUS-BD), a combination of a 19-gauge needle and a 0.025-inch guidewire is generally used. However, a 19-gauge needle has poor maneuverability because of their stiffness and rigidity and might have poor penetrability in non-dilated bile ducts because of their large bore. In contrast, the application of a 22-gauge needle is expected to have improved maneuverability. However, only a 0.018-inch guidewire, which has less supportability, is applicable in the subsequent guidewire selection. This study aimed to evaluate the feasibility and safety of a dedicated bougie dilator for a 0.018-inch guidewire. From September 2019 to May 2020, 26 patients underwent fistula dilation using the dilator after accessing the bile duct using a 22-gauge needle and a 0.018-inch guidewire during EUS-BD. The success and adverse event rates of EUS-BD were evaluated. Biliary access with a combination of a 22-gauge needle and a 0.018-inch guidewire was successful in all with a median bile duct diameter of 5mm. Dilation of the fistula using the dedicated dilator was also successful in all cases. Subsequently, the dilator was successfully exchanged to an ERCP catheter that allowed for exchange to a 0.025-inch guidewire, except in one case where the catheter did not cross the fistula and a dilation balloon was inserted for an exchange to a 0.025-inch guidewire. The technical success rate of the EUS-BD was 100%. The adverse event rate was 19%. The application of the dedicated dilator for a 0.018-inch guidewire was considered feasible and safe for EUS-BD.

ID: 3524324 PREDICTION OF POST-ERCP PANCREATITIS USING POST-PROCEDURE AMYLASE AND LIPASE LEVELS: A SYSTEMATIC REVIEW AND METAANALYSIS

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the mainstay procedure for managing pancreatic and biliary disorders. The most common complication of this procedure is acute pancreatitis, which occurs in 2-10% of the general population. However, Its frequency may go up to 40% in high-risk cases and is endoscopist dependent. Risk factors for post-ERCP pancreatitis (PEP) include young age, female sex, history of pancreatitis, non-dilated bile ducts, sphincter of Oddi dysfunction, etc. Early PEP prediction may allow safe same-day outpatients discharge after ERCP and earlier proper management. This meta-analysis aims to assess the usefulness of post-ERCP evaluation of pancreatic enzymes (lipase and amylase) in predicting PEP.

Continuous suture is a risk factor for benign hepaticojejunostomy stenosis after pancreatoduodenectomy in patients with a non-dilated bile duct.

It is unclear whether hepaticojejunostomy with a continuous suture is suitable for patients with a non-dilated bile duct. Medical records of patients who underwent pancreatoduodenectomy between 2003 and 2013 were retrospectively reviewed, focusing on the incidence of benign anastomotic stenosis and its relationship with suture method (continuous vs interrupted) and common hepatic duct size. Among 336 patients, 172 had a non-dilated (<8mm) duct, and the remaining 164 had a dilated duct. Benign stenosis occurred in 12.2% (21/172) in the former, but in only 0.6% (1/164) in the latter (p<0.001; median follow-up period, 43.5 months). Thus, further analysis was conducted in the 172 patients with a non-dilated duct, among whom 116 received a continuous suture and 56 received an interrupted suture. The cumulative incidence of benign anastomotic stenosis was significantly higher in patients who received a continuous suture vs those who received an interrupted suture (15.6% vs 1.8%, respectively, at 3 years; p=0.006). Multivariable analysis identified continuous suture, male gender, and cholangitis (within 3 months after surgery) as independent risk factors for benign stenosis. In this observational study, the use of a continuous suture was associated with benign anastomotic stricture in patients with a non-dilated hepatic duct.

Percutaneous transhepatic biliary drainage (PTBD) in patients with dilated vs. nondilated bile ducts: technical considerations and complications

ObjectivesThe aim of this study was to compare success, technical complexity, and complication rates of percutaneous transhepatic biliary drainage (PTBD) in patients with dilated vs. nondilated bile ducts.MethodsIn a retrospective analysis, we evaluated all consecutive PTBD performed in our department over a period of 5 years. Technical success, technical data (side, fluoroscopy time, radiation dose, amount of contrast media, use of disposable equipment), procedure-related complications and peri-interventional mortality were compared for patients with dilated vs. non-dilated bile ducts. Independent t test and χ2 test were used to evaluate the statistical significance.ResultsA total of 253 procedures were performed on 187 patients, of whom 101/253 had dilated bile ducts and 152/253 not. In total, 243/253 procedures were successful. PTBD was significantly more often successful in patients with dilated vs. nondilated bile ducts (150/153 vs. 93/101; p 0.02). Overall complication rate (13%) did not differ significantly between patients with dilated vs. nondilated bile ducts. Procedures in patients with normal, nondilated bile ducts were associated with a significantly higher rate of post-interventional bleeding (5/101 vs. 0/152). Mean fluoroscopy time (42:36 ± 35:39 h vs. 30:28 ± 25:10 h; p 0.002) and amount of contrast media (66 ± 40 ml vs. 52 ± 24 ml; p 0.07) or use of disposables were significantly higher in patients with nondilated ducts. A significantly lower fluoroscopy time and amount of contrast medium were used in left hepatic PTBD.ConclusionDespite the higher technical complexity, PTBD with nondilated bile ducts was associated with similar overall complication rates but higher bleeding complications compared with PTBD with dilated bile ducts.Key Points• PTBD was associated with similar overall complication rates in patients with dilated vs. nondilated bile ducts.• Although overall complication rates were low, PTBD in patients with nondilated bile ducts was associated with a higher incidence of post-interventional bleeding.• PTBD in patients with nondilated bile ducts is technically more complex.

Transcholecystic Contrast-Enhanced Ultrasound-Guided Percutaneous Transhepatic Biliary Drainage for Central Bile Duct Protection During Thermal Tumor Ablation

Intraductal cooling via a percutaneous transhepatic biliary drainage tube holds great promise in facilitating thermal ablation of liver tumors adjacent to the central bile ducts. However, the difficulties and complications associated with puncturing nondilated bile ducts are greater than those associated with puncturing dilated bile ducts. As reported here, percutaneous transcholecystic contrast-enhanced ultrasound was performed in 7 patients to visualize the nondilated bile ducts and guide percutaneous transhepatic biliary drainage, thus facilitating the intraductal cooling-assisted thermal ablation process. The procedures were technically successful in all 7 patients, and no major complications were recorded during the follow-up period.

Computed tomography features of acinar cell carcinoma of the pancreas

PurposeTo report the computed tomography (CT) features of pancreatic acinar cell carcinoma (ACC) and identify CT features that may help discriminate between pancreatic ACC and pancreatic ductal adenocarcinoma (PDA). Materials and methodsThe CT examinations of 20 patients (13 men, 7 women; mean age, 66.5±10.7 [SD] years; range: 51–88 years) with 20 histopathologically proven pancreatic ACC were reviewed. CT images were analyzed qualitatively and quantitatively and compared to those obtained in 20 patients with PDA. Comparisons were performed using univariate analysis with a conditional logistic regression model. ResultsPancreatic ACC presented as an enhancing (20/20; 100%), oval (15/20; 75%), well-delineated (14/20; 70%) and purely solid (13/20; 65%) pancreatic mass with a mean diameter of 52.6±28.0 (SD) mm (range: 24–120mm) in association with visible lymph nodes (14/20; 70%). At univariate analysis, well-defined margins (Odds ratio [OR], 7.00; P=0.005), nondilated bile ducts (OR, 9.00; P=0.007), visible lymph nodes (OR, 4.33; P=0.028) and adjacent organ involvement (OR, 5.67; P=0.02) were the most discriminating CT features to differentiate pancreatic ACC from PDA. When present, lymph nodes were larger in patients with pancreatic ACC (14±4.8 [SD]; range: 7–25mm) than in those with PDA (8.8±4.1 [SD]; range: 5–15mm) (P=0.039). ConclusionOn CT, pancreatic ACC presents as an enhancing, predominantly oval and purely solid pancreatic mass that most frequently present with no bile duct dilatation, no visible lymph nodes, no adjacent organ involvement and larger visible lymph nodes compared to PDA.

2284 Coagulopathy and Jaundice in Alagille Syndrome, Not All That Glitters Is Gold

INTRODUCTION: Alagille-Watson syndrome is an autosomal dominant disease associated with cardiac, hepatic and kidney abnormalities. Estimated prevalence of disease is 1 in 100,000 live births. Symptoms and severity of Alagille syndrome range from mild to cases requiring organ transplantation. CASE DESCRIPTION/METHODS: 32-year-old male patient with history of Alagille Syndrome s/p biliary diversion and right hemicolectomy at age 5 who was lost to follow up after he turned 18. Patient known to have Allele 1: 551 G &gt;A (R184H), Allele 2 with no mutation. Patient was admitted to the hospital with one month of worsening jaundice, fever and two episodes of non-bloody vomiting. Pertinent history included alcohol use 6-8 beers over the weekend for several years. Patient had baseline bilirubin of 2.4 and had elevated bilirubin for most of his life. On admission his AST/ALT were 209/143 U/L, bilirubin 18.6 mg/dl, direct 13.6 mg/dl; total bilirubin peaked at 24.4 mg/dl , INR was 10 and PTT was 51s. CBC and chemistries were normal. After vitamin K administration, INR corrected to 1.5. Patient received antibiotics and had negative blood and urine cultures. US done showed splenomegaly. MRCP showed a cirrhotic liver and nondilated bile ducts. Liver biopsy showed biliary cirrhosis, absent interlobular bile ducts, bile stasis and prominent Mallory Hyaline. Patient bilirubin levels improved and patient is currently undergoing liver transplant workup. DISCUSSION: 90% of patients with Alagille syndrome have bile duct paucity. This usually presents as cholestasis in the first four months of life, in our patient this issue improved with the biliary diversion. However this was complicated by low absorption of fat soluble vitamins. It is likely that infection and alcohol use contributed to his worsening liver disease. Pulmonic stenosis is the most common cardiac anomaly and most patients have classical syndromic facial features and butterfly vertebrae as did our patient. Posterior embryotoxon is also common. Conclusion: While 15% of nontransplanted patients with Alagille disease progress to cirrhosis, this case highlights that common liver diseases are still common in unique patient populations and should always be considered. Our patient alcohol intake contributed to his liver disease, his elevated INR was related to vitamin K deficiency rather than synthetic liver dysfunction, and marked improvement in his liver enzymes followed with alcohol cessation.

Antegrade X-ray surgical interventions in patients with choledocholithiasis in case of failed endoscopic procedures

Objective. To analyze safety and efficacy of X-ray surgical treatment of choledocholithiasis in case of failed endoscopic procedures. Material and methods. A retrospective analysis included 195 patients with choledocholithiasis who underwent X-ray surgical treatment. Primary X-ray surgical intervention was antegrade cholangiostomy. Data of antegrade cholangiography were used to determine type of endobiliary intervention. Antegrade mechanical and pneumatic choledocholithotripsy and lithoextraction, balloon dislocation of stones of the common bile duct into duodenum or jejunum, lithoextraction using rendezvous technique after endoscopic papillotomy through transpapillary drainage tube or a wire were applied. Results. Puncture and drainage of non-dilated bile ducts were successfully performed in 30 (15.4%) patients. There were 212 procedires of cholangiostomy in 195 patients including redo interventions. Complications after cholangiostomy were absent in 92.9% of cases. Minor complications occurred in 7.1% of cases. Antegrade mechanical and pneumatic choledocholithotripsy and lithoextraction was performed in 118 (98.3%) patients. Balloon dislocation of stones of the common bile duct into duodenum was applied in 52 (81.3%) patients. Lithoextraction using rendezvous technique after previous endoscopic papillosphincterotomy was performed in 12 (60%) patients. Six patients underwent transpapillary external-internal drainage of common bile duct. Five patients had stricture of biliodigestive anastomosis complicated by cholelithiasis. Lithotripsy and lithoextraction through antegrade approach or dislocation of stones into jejunum after previous balloon dilatation were performed in these patients. Postoperative mortality was 1.5%. Minimally invasive techniques were absolutely effective for choledocholithiasis in 187 (98.9%) patients. Conclusion. Antegrade X-ray surgical management is effective and safe in patients with choledocholithiasis and unsuccessful previous endoscopic procedures. Integral efficiency of antegrade management of cholelithiasis was 88.8%.

Opacification of nondilated bile ducts through the gallbladder as an aid to percutaneous transhepatic biliary drainage.

The purpose of this study was to retrospectively assess the potential of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated bile ducts (NDBD) using a transgallbladder opacification of the bile ducts. Eight patients with NDBD (7 men, 1 women; median age, 65 years; Q1-Q3, 35-69 years; range, 22-77 years) who underwent PTBD after opacification of the bile ducts through the gallbladder were evaluated. Opacification of NDBD was performed using a retrograde injection of contrast material through the gallbladder. The opacified peripheral NDBD was punctured percutaneously and a drainage catheter was introduced under fluoroscopy guidance. The success and safety of the procedure were assessed. PTBD could be achieved in 6/8 patients (75%) and no significant complications were observed. The biliary tree opacification was attempted but could not be achieved due to biliary sludge that obstructed the cystic duct in 2/8 patients (25%). Two minor complications in two different patients were observed consisting of transient hemobilia and chills. Opacification of the bile ducts using a transgallbladder approach appears to be a safe and successful procedure for PTBD in patients with NDBD.

Hybrid Approach for Biliary Interventions Employing MRI-Guided Bile Duct Puncture with Near-Real-Time Imaging.

To assess the feasibility of a hybrid approach employing MRI-guided bile duct (BD) puncture for subsequent fluoroscopy-guided biliary interventions in patients with non-dilated (≤3mm) or dilated BD (≥3mm) but unfavorable conditions for ultrasonography (US)-guided BD puncture. A total of 23 hybrid interventions were performed in 21 patients. Visualization of BD and puncture needles (PN) in the interventional MR images was rated on a 5-point Likert scale by two radiologists. Technical success, planning time, BD puncture time and positioning adjustments of the PN as well as technical success of the biliary intervention and complication rate were recorded. Visualization even of third-order non-dilated BD and PN was rated excellent by both radiologists with good to excellent interrater agreement. MRI-guided BD puncture was successful in all cases. Planning and BD puncture times were 1:36±2.13 (0:16-11:07) min. and 3:58±2:35 (1:11-9:32) min. Positioning adjustments of the PN was necessary in two patients. Repeated capsular puncture was not necessary in any case. All biliary interventions were completed successfully without major complications. A hybrid approach which employs MRI-guided BD puncture for subsequent fluoroscopy-guided biliary intervention is feasible in clinical routine and yields high technical success in patients with non-dilated BD and/or unfavorable conditions for US-guided puncture. Excellent visualization of BD and PN in near-real-time interventional MRI allows successful cannulation of the BD.

Predicting difficulty in laparoscopic cholecystectomy by clinical, hematological and radiological evaluation

Background: Laparoscopic cholecystectomy (LC) has become the gold standard in the treatment of symptomatic cholelithiasis. It has revolutionized minimally invasive procedures. Laparoscopic cholecystectomy may be rendered difficult by various problems encountered during surgery. The aim of this study was to predict difficulty of LC and possibility of conversion to open cholecystectomy (OC) before surgery using the clinical, haematological and ultrasonographic criteria. Methods: This study was carried out on 50 patients with symptomatic cholelithiasis, non-dilated bile ducts. All patients underwent abdominal ultrasound examination. All cases underwent laparoscopic cholecystectomy with assessment of the difficulties encountered. Results: LC was successfully accomplished in 49 patients (98%) with a mean operative time of65.122 ± 26.87 minutes. Adhesions present in 14 cases (28%). Gall bladder bed dissection was difficult in 4 patients (8%). Aberrant anatomy present in 4 cases (8 %) while stone spillage occurred in 3 patients (6%) and were all retrieved. Extraction of the excised gall bladder was difficult in 4 patients (8%). Conversion to laparotomy occurred in 1 patients (2%). The preoperative parameters that significantly predicted difficult LC were based on the presence of BMI >27.5, history of prior hospitalization, palpable gallbladder, ultrasonographic features of impacted stone and gall bladder wall thickening. Conclusions: Preoperative evaluatuion may help predict a difficult LC. This information may be useful to both the patient and the treating surgeon.

Diagnostic Accuracy of Magnetic Resonance Cholangio- Pancreatography in Choledocholithiasis

Objectives: To estimate the diagnostic accuracy of MRCP in the detection of bile duct calculi in patients with obstructive jaundice using ERCP as gold standard. Study Design: This is a cross sectional study. The study was conducted at Department of Diagnostic Radiology and Imaging Civil Hospital Karachi, from 01-08-2013 to 31-12-2014. Materials & Methods: This study comprises 249 cases of clinically observed obstructive jaundice which were referred by hospital consultants or by general practitioner to the Radiology Department for Magnetic Resonance Cholangio-Pancreatography (MRCP). Inclusion criteria were Patients of either gender between 26- 70 years of age with obstructive jaundice, raised direct bilirubin levels of 3 mg/dl and above, raised alkaline phosphatase levels and abdominal ultrasound showed suspicion of stone in dilated or non-dilated common bile duct. Previously Diagnosed cases of Choledocholithiasis, patients of chronic liver disease and those for which MRI is contraindicated such as those with surgical clips, braces were excluded from the study. Standard MRI technique carried out for evaluation of bile duct calculi in obstructive jaundice patients. Its features were carefully evaluated in terms of presence and absence of calculus / calculi, dilatation of CBD and pancreatic duct and presence of intrahepatic cholestasis by the consultant radiologist. Data entered and Statistical analyses were carried out by using SPSS version 17. Sensitivity, specificity, diagnostic accuracy positive and negative predictable values were calculated. Mean and frequency distribution for ages and gender was calculated respectively. Results: Mean age of the patients was 45.54 ±11.352 years. Gender distribution shows, 42 patients (17%) were male while remaining 207 patients (83%) were female. True positive cases for stones were 145 (58%) and false positive cases were 80 (32%). Positive predictive value was 91.77%, negative predictive value 87.91% with sensitivity 92.95%, specificity 86.02% and Diagnostic accuracy were found to be 90.36%. Conclusion: It is conclude that Magnetic Resonance Cholangio-Pancreatography (MRCP) is a safe, precise, relatively fast, with no ionizing radiation and non-invasive imaging modality for the assessment of common bile duct stones in patients of obstructive jaundice. The result of this study recommends that MR Imaging showed high Sensitivity and positive predictive values in the detection of bile duct calculi.

Cholestatic hepatitis as a clinical mask of choledocholithiasis

The variety of cholelithiasis clinical manifestations, seriously impeding the timely diagnosis, are well known. This is determined by multiple impairment of interorgan communication in cholelithiasis. The most difficult form of cholelithiasis both for identification, and for treatment is choledocholithiasis. Diagnosis of stones in the common bile duct is based on a complex of clinical, laboratory and instrumental data. The appearance of jaundice amid the abdominal pain and revealing signs of biliary hypertension during instrumental examination are considered typical for choledocholithiasis. Particular difficulties for the diagnosis are choledocholithiasis cases with atypical pain syndrome, the absence of jaundice and non-dilated bile ducts. One of the reasons for the variability of pain syndrome in cholelithiasis is polymorbidity of these patients. Relatively frequently, bile duct stones are combined with a hiatal hernia, which is pathogenetically interdependent. Clinical manifestations in such cases depends on what syndrome is the dominant. Non-dilated bile ducts in patients with proven choledocholithiasis was detected in 5.8% of patients. In this situation, the presence of cholestasis and cytolysis biochemical markers in the absence of instrumental signs of biliary hypertension can simulate intrahepatic cholestasis. Clinical case demonstrating the difficulty of choledocholithiasis diagnosis is presented. In a given clinical observation the patient with a history of cholecystectomy for cholelithiasis; with intense abdominal pain, primarily appraised as a manifestation fixed hiatal hernia; pronounced anicteric cholestatic syndrome, was presented. No signs of biliary hypertension in the standard transabdominal ultrasound examination of the abdomen required exclusion of intrahepatic causes of cholestasis. In-depth instrumental and laboratory examination allowed to diagnose in patient choledocholithiasis. It is proposed to mark out variant of the cholelithiasis course with the stones localization in the common bile duct under the guise of cholestatic hepatitis.

Short-Term Biliary Stent Placement Contributing Common Bile Duct Stone Disappearance with Preservation of Duodenal Papilla Function.

Aims. To investigate the effect of biliary stent placement without endoscopic sphincterotomy (EST) on common bile duct stones (CBDS) disappearance and the contribution of preserving the duodenal papilla function to reduce recurrence of CBDS. Methods. Sixty-six patients admitted for acute obstructive cholangitis due to CBDS who underwent biliary stent placement without EST for 2 years from March 2011 were evaluated retrospectively. The second endoscopic retrograde cholangiopancreatography (ERCP) was performed for treatment of CBDS 3 to 4 months after the first ERCP. We estimated the rate of stone disappearance at the time of second ERCP. Results. CBDS disappearance was observed in 32 (48.5%) of 66 patients. The diameter of the bile ducts and the diameter of CBDS in patients with CBDS disappearance were significantly smaller than in those with CBDS requiring extraction (p = 0.007 and p < 0.001, resp.). Stone disappearance was evident when the diameter of bile ducts and that of CBDS were <10 and 7 mm, respectively (p = 0.002). Conclusions. Short-term stent placement without EST eliminates CBDS while preserving duodenal papilla function and may be suitable for treating CBDS in patients with nondilated bile ducts and small CBDS.

Peripheral portal vein-oriented non-dilated bile duct puncture for percutaneous transhepatic biliary drainage.

To evaluate the efficacy of peripheral portal vein (PV)-oriented non-dilated bile duct (BD) puncture for percutaneous transhepatic biliary drainage (PTBD). Thirty-five patients with non-dilated BDs underwent PTBD for the management of various biliary disorders, including benign bilioenteric anastomotic stricture (n = 24), BD stricture (n = 5) associated with iatrogenic BD injury, and postoperative biliary leakage (n = 6). Under ultrasonographic guidance, percutaneous transhepatic puncture using a 21-G needle was performed along the running course of the peripheral targeted non-dilated BD (preferably B6 for right-sided approach, and B3 for left-sided approach) or along the accompanying PV when the BD was not well visualized. This technique could provide an appropriate insertion angle of less than 30° between the puncture needle and BD running course. The puncture needle was then advanced slightly beyond the accompanying PV. The needle tip was moved slightly backward while injecting a small amount of contrast agent to obtain the BD image, followed by insertion of a 0.018-inch guide wire (GW). A drainage catheter was then placed using a two-step GW method. PTBD was successful in 33 (94.3%) of the 35 patients with non-dilated intrahepatic BDs. A right-sided approach was performed in 25 cases, while a left-sided approach was performed in 10 cases. In 31 patients, the first PTBD attempt proved successful. Four cases required a second attempt a few days later to place a drainage catheter. PTBD was successful in two cases, but the second attempt also failed in the other two cases, probably due to poor breath-holding ability. Although most patients (n = 26) had been experiencing cholangitis with fever (including septic condition in 8 cases) before PTBD, only 5 (14.3%) patients encountered PTBD procedure-related complications, such as transient hemobilia and cholangitis. No major complications such as bilioarterial fistula or portal thrombosis were observed. There was no mortality in our series. Peripheral PV-oriented BD puncture for PTBD in patients with non-dilated BDs is a safe and effective procedure for BD stricture and postoperative bile leakage.