Normal Cholangiogram Research Articles

Primary sclerosing cholangitis-A long night's journey into day.

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Predictors of recurrent bile duct stone after clearance by endoscopic retrograde cholangiopancreatography: A case-control study

BackgroundRecurrent common bile duct (CBD) stone is a long-term sequalae among patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stone extraction. Data regarding risk factors for recurrent CBD stone are scarce. We aimed to identify predictors of recurrent CBD stone. MethodsWe performed a retrospective case-controlled study from January 2010 to December 2019. Inclusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP, in which complete stone extraction was performed and normal cholangiogram was obtained. Overall, 457 patients were included. Forty-two patients (9.2%) had recurrent CBD stone, and 415 patients (90.8%) did not have recurrent CBD stone. ResultsIn univariate analysis, male sex [odds ratio (OR) = 0.49, P = 0.033] was a protective factor, while endoscopic stone extraction by basket vs. balloon (OR = 2.55, P = 0.005), older age (OR = 1.03, P = 0.003), number of CBD stones (OR = 1.99, P = 0.037), size of CBD stone (OR = 4.06, P = 0.003) and mechanical lithotripsy (OR = 9.22, P = 0.004) were risk factors for recurrent CBD stone. In multivariate logistic regression analysis, mechanical lithotripsy [OR = 9.73, 95% confidence interval (CI): 1.69–55.89, P = 0.010], basket clearance vs. combined basket and balloon (OR = 18.25, 95% CI: 1.05–318.35, P = 0.046) and older age (OR = 1.02, 95% CI: 1.00–1.05, P = 0.023) were risk factors, and male sex (OR = 0.39, 95% CI: 0.19–0.81, P = 0.012) was a protective factor. ConclusionsWe identified modifiable and non-modifiable risk factors for recurrent CBD stone. Taking into consideration those factors might aid in minimizing the CBD stone recurrence risk.

S1521 Ectopic Location of the Ampulla of Vater in the Pyloric Channel

INTRODUCTION: The ampulla of Vater can be ectopically located in stomach, pylorus, or duodenum with the duodenum comprising the majority of cases. The prevalence of this abnormality is rare, nonetheless it has important clinical ramifications. Given the unusual anatomy, patients may be at higher risk of ulceration, stenosis, and choledocholithiasis while accompanying ERCP can be more challenging and time consuming. CASE DESCRIPTION/METHODS: A 90-year-old gentleman presented to his PCP with 4 weeks of RUQ abdominal pain. His past medical history was significant for a non-healing pyloric channel ulcer resulting in gastric outlet obstruction, initially treated with balloon dilation and subsequently with gastrojejunostomy. Laboratory examination showed a total bilirubin of 0.7, ALP 877, AST 129, and ALT 168. MRCP revealed a dilated bile duct to 15 mm with a large stone seen in the distal CBD. On ERCP, the gastrojejunostomy appeared patent without ulceration or stenosis. However, a 1.5 cm pyloric channel ulcer was seen resulting in pyloric stenosis (Figure 1). This was successfully dilated to 15 mm using a wire guided balloon with subsequent advancement of the duodenoscope into the second portion of the duodenum. After careful inspection, the ampulla was eventually discovered to be ectopically located in the pyloric channel with surrounding ulceration (Figure 2). Cholangiogram showed a large stone within the bile duct, which was treated with balloon sphincteroplasty, balloon sweeps with stone removal, and a double pigtail stent placement (Figure 3). The patient was subsequently started on high dose PPI therapy. Repeat ERCP in 3 months showed complete healing of the pyloric channel ulcer and a normal cholangiogram with no residual stones. Patient had repeat LFT’s 6 weeks post-procedure which were normal. DISCUSSION: Ectopic major papilla in the pyloric channel can lead to pyloric channel ulceration secondary to mucosal injury caused by chronic flow of bile and pancreatic digestive enzymes to this region. The anomalous bile drainage also increases the predisposition for development of choledocholithiasis. Balloon sphincteroplasty is the preferred method of stone removal in these patients given the increased perforation risk of sphincterotomy due to lack of anatomical landmarks.Figure 1.: Pyloric channel ulcer resulting in GOO.Figure 2.: Ectopic ampulla of Vater with bile duct (red arrow) and pancreatic duct (green arrow) opening.Figure 3.: Balloon sphincteroplasty (red arrow showing CBD stone).

S2498 Vismodegib, a Hedgehog Pathway Inhibitor, Causing Severe Liver Injury

INTRODUCTION: Vismodegib, a hedgehog pathway inhibitor used to treat locally advanced and metastatic basal cell carcinoma, can lead to severe hepatotoxicity. Patients who develop nausea, loss of appetite, and dysgeusia should have liver enzymes evaluated. Early detection of liver insult could lead to early discontinuation of the drug to prevent worsening liver injury, further workup and unnecessary hospitalization. CASE DESCRIPTION/METHODS: A 53 year old female with invasive basal cell carcinoma on vismodegib, presented with loss of appetite, RUQ abdominal pain and jaundice. Labs revealed a total bilirubin of 7.4 mg/dL, alkaline phosphatase 545 IU/L, AST 163 IU/L, and ALT 471 IU/L. Viral hepatitis and autoimmune panel was unremarkable. MRCP and an endoscopic ultrasound did not show any biliary obstruction. However, the biliary ducts appeared unusually small. Her bilirubin continued to increase, and the idea of vismodegib causing cholestatic liver injury and vanishing bile duct syndrome was entertained. However, ERCP revealed a normal cholangiogram. Liver biopsy was pursued and showed marked zone 3 canalicula cholestasis and marked duct injury in portal tracts suggesting vismodegib causing cholestatic liver injury. DISCUSSION: There have been a few cases now reporting vismodegib-induced liver injury. Luckily our patient slowly improved with drug withdrawal. However, there has been life-threatening hepatotoxicity and even death, especially in patients taking drugs with potential hepatotoxic effects. Liver enzymes can mimic the pattern of acute viral or autoimmune hepatitis or ischemic liver injury. Our initial suspicion given our patient's MRCP and EUS findings, with bile ducts appearing abnormally small, was drug-induced vanishing bile duct syndrome. Vanishing bile duct syndrome in adults is typically caused by autoimmune diseases, neoplasms such as Hodgkin’s lymphoma, infections such as CMV and drugs such as allopurinol. The diagnosis is made through liver biopsy containing at least 10 portal tracts, showing loss of interlobular bile ducts in > 50% of the portal tracts. Clinically, patients will have fatigue, weight loss, loss of appetite, and abdominal pain as a result of intrahepatic cholestasis. Treatment includes discontinuation of offending drug but others have trialed ursodiol. Our patient’s liver biopsy did not suggest this rare syndrome but we suspect that if she had continued vismodegib, her outcome could have been worse and her liver biopsy could have progressed to vanishing bile duct syndrome.Figure 1.: Magnetic resonance cholangiopancreatography did not show any evidence of obstruction. Biliary ducts appeared small.Figure 2.: Endoscopic retrograde cholangiopancreatography was unremarkable, without evidence of obstruction.

Development and validation of a new simplified diagnostic scoring system for pediatric autoimmune hepatitis

BackgroundChildren with autoimmune hepatitis (AIH) often exhibit particular features. Accordingly, seven pediatric-specific criteria have been proposed. AimTo develop a prediction model based on them, transform it into a scoring system and study its accuracy. MethodsA cohort of children under study for liver disease was consecutively selected. AIH diagnosis was based on classical criteria. Already proposed pediatric criteria were recorded. The best possible regression model was selected, and the beta coefficient of each criterion was translated into a whole number (points). Total scores were obtained following the points system and the best cut-off was calculated. Subsequently, accuracy of the diagnostic score was studied in the validation set. ResultsAmong 212 included patients, 100 had AIH. The score included 5 criteria: autoantibodies (0–2 points), hypergammaglobulinemia, exclusion of viral hepatitis, exclusion of Wilson’s disease (1 point each) and liver histology (3 points). In addition, a normal cholangiogram is mandatory. The validation set was formed of 70 patients (24 with AIH). In this subsample, a score of ≥6 renders a sensitivity/specificity of 95.8%/100%. The area under the receiver operating characteristic curve was 97.1%. ConclusionPediatric-specific criteria for the diagnosis of AIH can be reliably used as a scoring system.

Got a Leak! Letʼs Glue It

Introduction: The procedure of choice for management of acute cholecystitis is laparoscopic cholecystectomy (LC). LC has it's distinct advantages; however, post-operative refractory bile leaks present a significant therapeutic challenge. Herein, we report a case of endoscopic occlusion of high grade bile leak from the gall bladder remnant that failed all standard endoscopic maneuvers via the use of human pooled plasma fibrinogen and thrombin (HPF) (Tissel, Baxter, CA) as a sealant. Case: A 65-year-old male presented with abdominal pain and was found to have CT and HIDA scan findings consistent with acute cholecystitis. Laparoscopic evaluation revealed severely inflamed and gangrenous gall bladder, hence he underwent an open subtotal cholecystectomy. Post operatively, patient had increased bilious output from the JP drain, therefore, a CT scan abdomen was done which revealed a biloma in the gall bladder fossa. ERCP revealed a high grade bile leak from the gall bladder remnant and suggestion of ampullary stenosis. Biliary sphincterotomy was performed and a 10 Fr x 5 cm plastic stent was placed in the common bile duct (CBD). Due to persistent high output from the JP drain, a repeat ERCP was done 4 weeks later; occlusion cholangiogram revealed low grade bile leak from the gall bladder remnant. Balloon sweep with clearance of biliary sludge was performed and the plastic stent was interchanged with a 10 mm x 6 cm fully covered self-expanding metal stent (FC-SEMS). Six weeks after placement of the FC-SEMS, patient still had persistent bilious drainage from the JP drain therefore a third ERCP was done. The previously placed biliary stent was removed and cholangiogram revealed a high grade bile leak. No filing defects or stricture were noted in the CBD. The CBD was dilated to 10 mm and the cystic duct stump was successfully cannulated and injected with 3 ml of HPF for the purpose of sealing the leak. Repeat cholangiogram demonstrated no leak. A 10 mm x 80 mm FC-SEMS was placed in the common bile duct. Follow up ERCP 3 months later revealed normal cholangiogram with no evidence of ongoing bile leak and the FC-SEMS was removed. Discussion: To our knowledge this a first report demonstrating use of HPF endoscopically for successful management of refractory bile leak. HPF should note be injected into vascular structures due to concern for vascular thrombosis. Further studies and reports are needed to evaluate the safety and efficacy of this technique.

Spontaneous biloma: Report of two cases with review of the literature

INTRODUCTION Biloma is the collection of bile outside the biliary tree and can be intra or extra hepatic. It is most commonly iatrogenic, secondary to surgery or percutaneous transhepatic procedures or secondary to abdominal trauma. Spontaneous bilomas are very rarely described in the literature. CASE REPORT A 32 years old female presented as lump abdomen in epigastric region. Blood investigations were normal. Chest radiographs were unremarkable. Ultrasound examination revealed two cystic lesion in relation to left lobe of liver and cholelithiasis with choledocholithiasis. Ultrasound guided pigtail catheter drainage of the collection was done. ERCP failed to manage the choledocholithiasis. CBD exploration with choledocholithotomy and T-tube drainage and cholecystectomy was done. The postoperative period was uneventful, and the T-tube was removed on the 10th day after a normal T-tube cholangiogram. CASE 2 32 year old female admitted in emergency with complain of acute pain in abdomen since 2 days. Ultrasound shows contracted gallbladder withstone along with focal collection in perihepatic and peri gallbladder region extending into subcutaneous plane with cbd stone.. Ultrasound guided pigtail catheter drainage of the collection was done. After 5 days she underwent ERCP by which cbd stones were cleared. Elective laparoscopic cholecystectomy was done. CONCLUSION A high index of clinical suspicion is necessary for prompt recognition and its proper management. Percutaneous treatment should be considered as the first-line option for patients with spontaneous biloma. In cases of persistent bile leaks, endoscopic biliary drainage and endoscopic sphincterotomy with or without stent placement should be performed. Surgery is now performed only in cases with a persistent bile leak or for treatment of an underlying disease.

Vision loss: another ERCP-related adverse event, also known as isolated bilateral lateral geniculate body infarction

A 22-year-old healthy woman experienced intermittent epigastric pain 3 weeks after an uncomplicated pregnancy. Cholecystitis was diagnosed on the basis of US, and cholecystectomy was scheduled in 2 weeks. Because of the persistence of intermittent pain and mild laboratory evidence of cholestasis, with bilirubin total of 1.6 mg/dL, the patient underwent preoperative ERCP because of a concern for choledocholithiasis, despite normal common bile duct (CBD) on US (A) and no symptoms of cholangitis. ERCP with precut sphincterotomy to facilitate CBD cannulation and subsequent balloon-sweep revealed a normal cholangiogram (B). An indomethacin suppository was given. Within 24 hours after ERCP, the patient experienced severe epigastric pain. Acute pancreatitis was diagnosed on the basis of lipase 2200 units/L. Intravenous fluids were started 12 hours later. Simultaneously, the patient experienced rapidly progressing, painless, bilateral vision loss, necessitating transfer to our hospital. Her pain resolved within 72 hours; however, the result of neurologic examination was pertinent for persistent profound bilateral vision loss but was otherwise nonfocal, with normal fundoscopic examination results. Magnetic resonance imaging of the brain revealed bilateral lateral geniculate body infarcts (C). Given the temporal relationship to post-ERCP pancreatitis, a watershed infarction was suspected, likely resulting from temporary hypotension. The result of a comprehensive evaluation for other causes of stroke, including vasculitis and hypercoagulability, was negative. Because potentially severe ERCP-related adverse events can occur, the correct procedure indication is crucial.

Evaluation of patients with abnormalities on intraoperative cholangiogram: time to abandon endoscopic retrograde cholangiopancreatography as the initial follow-up study

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on intraoperative cholangiogram (IOC); however, the sensitivity of IOC for...

Do Patients with Acute Cholecystitis with Elevated Liver Function Tests and a Normal Cholangiogram Have Different Outcomes than Those with Normal Liver Function Tests?

Do Patients with Acute Cholecystitis with Elevated Liver Function Tests and a Normal Cholangiogram Have Different Outcomes than Those with Normal Liver Function Tests?

Hepatopancreatobiliary manifestations of inflammatory bowel disease.

Inflammatory bowel disease (IBD) is frequently associated with extraintestinal manifestations such as hepatopancreatobiliary manifestations (HPBMs), which include primary sclerosing cholangitis (PSC), pancreatitis, and cholelithiasis. PSC is correlated with IBD, particularly ulcerative colitis (UC); 70-80% of PSC patients in Western countries and 20-30% in Japan have comorbid UC. Therefore, patients diagnosed with PSC should be screened for UC by total colonoscopy. While symptoms of PSC-associated UC are usually milder than PSC-negative UC, these patients have a higher risk of colorectal cancer, particularly in the proximal colon. Therefore, regular colonoscopy surveillance is required regardless of UC symptoms. Administration of 5-aminosalicylic acid or ursodeoxycholic acid may prevent colorectal cancer and cholangiocarcinoma. While PSC is diagnosed by diffuse multifocal strictures on cholangiography, it must be carefully differentiated from immunoglobulin G4 (IgG4)-associated cholangitis, which shows a similar cholangiogram but requires different treatment. When PSC is suspected despite a normal cholangiogram, the patient may have small-duct PSC, which requires a liver biopsy. IBD patients have a high incidence of acute and chronic pancreatitis. Most cases are induced by cholelithiasis or medication, although some patients may have autoimmune pancreatitis (AIP), most commonly type 2 without elevation of serum IgG4. AIP should be accurately identified based on characteristic image findings, because AIP responds well to corticosteroids. Crohn's disease is frequently associated with gallstones, and several risk factors are indicated. HPBMs may influence the management of IBD, therefore, accurate diagnosis and an appropriate therapeutic strategy are important, as treatment depends upon the type of HPBM.

Natural history of small duct primary sclerosing cholangitis: a case series with review of the literature

Information about the natural history of small duct primary sclerosing cholangitis (SDPSC) remains scant despite literature suggesting that it constitutes 6-16% of all cases of primary sclerosing cholangitis (PSC). We combined clinical data on SDPSC cases from two tertiary care institutions with liver transplantation programs with the aim of studying the natural history of SDPSC. Medical records of 25 individuals with SDPSC were reviewed. Diagnosis of SDPSC was based on liver biopsy findings consistent with PSC, a normal cholangiogram, and elimination of known causes of secondary sclerosing cholangitis. Demographic information, symptoms, past medical history, laboratory values, and histologic data were evaluated. Our primary outcome measure was liver transplantation or death. Secondary outcome measures included evidence of end-stage liver disease, development of cholangiocarcinoma, and/or the development of classic PSC on a repeat cholangiogram. Data on 25 individuals (13 males, 12 females; mean age 40±15years) diagnosed with SDPSC were analyzed. Upon presentation, 11 patients had symptoms including abdominal pain, fatigue, and pruritus. Inflammatory bowel disease was present in 14 patients (56%) at diagnosis. On initial liver biopsy, 60% had early-stage disease (I or II) and none had cirrhosis. On follow-up (1-168months, median 17months), malignancy or progression to classic large duct PSC was not noted. Two (8%) patients had evidence of varices and one of the two also developed ascites; one of these patients underwent liver transplantation and the other one died due to sepsis. SDPSC, a mild disease at presentation typically runs a benign course and likely is not an early stage of classic PSC. Further studies with a control group of classic PSC and longer follow-up are needed to study the natural history of SDPSC.

Jejunal access loop cholangiogram and intervention using image guided access

Jejunal access loop is fashioned in patients who undergo Roux en Y hepaticojejunostomy and biliary intervention is anticipated on follow up. Post-operative study of the biliary tree through the access loop is usually done under fluoroscopic guidance. We present a series of 20 access loop cholangiograms performed in our institution between August 2004 and November 2008. We aimed to evaluate the safety and efficacy of the procedure and to highlight the role of CT guidance in procuring access. Access loop was accessed using CT (n = 13), ultrasound (n = 3) or fluoroscopic guidance (n = 4). Fluoroscopy was used for performing cholangiograms and interventions. Twelve studies had balloon plasty of the stricture at anastomotic site or high up in the hepatic ducts. Seven studies showed normal cholangiogram. Plasty was unsuccessful in one study. Technical success in accessing the jejunal access loop was 100%; in cannulation of anastomotic site and balloon plasty it was 95%. One case required two attempts. Procedure-related complications were not seen. All patients who underwent balloon plasty of the stricture were doing well for variable lengths of time. Access loop cholangiogram and interventions are safe and effective. CT guidance in locating/procuring the access loop is a good technique.

Ranitidine-induced Hepatitis: A Rare Cause of Hepatotoxicity

Purpose: Introduction: Ranitidine and other histamine 2 receptor antagonists (H2RA) remain in use for acid-related disorders. This drug class is considered extremely safe, resulting in use without a prescription. Despite this, it is rarely associated with severe hepatotoxicity. Case: A 27 year old male, without significant past medical history, presented to Cabell Huntington Hospital with jaundice and mild RUQ discomfort of three days duration. Medication use at presentation was over-the-counter (OTC) ranitidine for intermittent epigastric pain and heartburn only. Active alcohol or drug use was not reported by the patient. Physical examination was significant for clinical jaundice and mild RUQ tenderness. No hepatosplenomegaly was noted. Laboratory data revealed a WBC count of 4.3 × 103/mm3, AST of 1385 U/L, ALT 2544 U/L, total bilirubin of 10.7 g/dl, direct bilirubin of 7.5 g/dL, alkaline phosphatase 199 U/L, ferritin >1650 ng/ml, iron saturation of 62.1%., PT 14.5 seconds and INR 1.47. Acute viral hepatitis panel was negative. CMV and EBV serologies along with anti-mitochondrial, anti-nuclear and anti-smooth muscle antibodies were negative. Alpha-1-antitrypsin and ceruloplasmin serum levels were normal. HFE gene mutation was negative. Abdominal CT discovered a 6 mm gallstone only. ERCP revealed a normal cholangiogram without ductal dilation, choledocholithiasis or sludge. Liver biopsy showed mild portal inflammation, predominantly small lymphocytes and a few eosinophils with mild lobular inflammation. Intrahepatic cholestasis was present, but no viral cytopathic effects or evidence of iron overload. Trichrome stain demonstrated minimal portal fibrosis. These findings suggested drug-induced hepatitis, likely due to ranitidine, as the sole medication used. This was discontinued at admission. All laboratory abnormalities at presentation returned to the normal range over the following 7 weeks. Discussion: Ranitidine-associated acute hepatitis has been estimated to occur in less than 1 per 100,000 patients and appears to be idiosyncratic in nature. In most reported cases, the association was not clear due to confounders including other potential hepatotoxic medications at presentation, recent vaccination or preexisting liver disease. Other cases had incomplete evaluation including the absence of liver biopsy, autoimmune or viral serologies as well as lack of endoscopic or radiologic biliary tree evaluation. Conclusion: This case highlights the seriousness of drug-induced hepatitis caused by a widely used OTC medication. All clinical symptoms and biochemical abnormalities disappeared within 2 months of ranitidine withdrawal.

Absence of glycochenodeoxycholic acid (GCDCA) in human bile is an indication of cholestasis: A 1H MRS study

The utility of (1)H MR spectroscopy in detecting chronic cholestasis has been investigated. The amide proton region of the (1)H MR spectrum of human bile plays a major role in differentiating cholestatic (Ch) patterns from the normal ones. Bile obtained from normal bile ducts contains both taurine and glycine conjugates of bile acids--cholic acid (CA), chenodeoxycholic acid (CDCA), and deoxycholic acid (DCA). Absence of a glycine-conjugated bile acid glycochenodeoxycholic acid (GCDCA) has been observed in bile samples obtained from primary sclerosing cholangitis (PSC) patients. A total of 32 patients with various hepatobiliary diseases were included in the study. Twenty-one patients had PSC and 11 had normal cholangiograms. One PSC patient was excluded from the study because of a bad spectrum. Seventeen out of the 20 PSC patients showed an absence of GCDCA in their (1)H MR spectrum of bile. Six of the 11 reference patients with normal cholangiogram also showed spectra similar to those of PSC, indicating the possibility of cholestasis. DQF-COSY and TOCSY experiments performed on bile samples from PSC patients also revealed absence of phosphatidylcholine (PC) in some of the bile samples, suggesting possible damage to the cholangiocytes by the toxic bile. These observations suggest that analysis of human bile by (1)H MRS could be of value in the diagnosis of chronic Ch liver disorders.

What Is the Impact of Biliary Intraductal Ultrasound in Daily Clinical Practice?

Background: Intraductal ultrasound (IDUS) is useful for determining the nature of biliary strictures, staging of biliary cancer, and in detecting bile duct stones. There are limited published data on its actual clinical utility in a heterogeneous patient population undergoing endoscopic retrograde cholangiopancreatography (ERCP). Aim: This study evaluated the actual impact of biliary intraductal ultrasound in a heterogeneous patient population in daily clinical practice. Methods: This was a single center study conducted over a period of 20 months. The inclusion criterion was the need for adjunctive biliary IDUS when ERCP findings were indeterminate, such as the presence of strictures of unclear etiology or a seemingly normal cholangiogram without any filling defects when choledocholithiasis was suspected on basis of clinical presentation. Biliary IDUS was performed using a wire-guided mini-probe with 20MHz frequency (UM-G20-29R, Olympus, Tokyo, Japan). A true positive was defined on basis of results of brush cytology or surgical histology, or through documentation of actual stone extraction in the context of suspected common bile duct (CBD) stones. Patients with negative IDUS findings were followed up and considered true negatives in the absence of clinical symptoms and normal liver function tests at 6-month follow up. A positive clinical impact was defined as achieving a positive clinical diagnosis or affecting subsequent management strategy. Results: Forty-five (8.2%) of 552 patients who underwent ERCP had indeterminate ERCP findings that required further evaluation with biliary IDUS. IDUS was technically successful in all cases. The mean age was 60.7 years (range: 33 - 92), with 62.2% male. ERCP showed apparently normal CBD in 22 (48.9%), dilated CBD of unclear etiology in 8 (17.8%) and a CBD stricture in 15 (33.3%) patients. Among the patients with either apparently normal CBD or dilated CBD of unclear etiology, an occult CBD stone (mean size 2.5mm; range: 1.1 - 6.6) was found in 27/30 (90%), with the remaining cases being normal. Among patients with strictures, Mirizzi syndrome was diagnosed in 7/15 (46.7%), cholangiocarcinoma in 4/15 (26.7%), malignant IPMN in 1/15 (6.7%) and benign fibrotic stricture in 2/15 (13.3%). One patient with biliary stricture was wrongly diagnosed as biliary hydatid disease based on a cystic appearance; subsequent surgery revealed hepatobiliary cystademona. Overall biliary IDUS had a positive clinical impact in 39/45 (86.7%). Conclusion: Biliary IDUS increases the diagnostic accuracy of ERCP. It is a very useful adjunctive test when ERCP findings are indeterminate.

Diagnostic and Therapeutic ERCP in Long-Limb Surgical Bypass Patients Using a New Single-Balloon Assisted Enteroscope

Background: Successful per-oral ERCP has been reported in long-limb surgical bypass patients, including Roux-en-Y cases, using standard push enteroscopes (Howell, GIE 1996;43: 383AB). Newer bypass procedures have resulted in increased length of bypass limbs preventing endoscopic access with standard equipment. The single-balloon overtube assisted enteroscope (SBAE)(Olympus America) has recently been released. We report initial experience performing per-oral ERCP using SBAE. Patients and Methods: 10 procedures were attempted in 8 pts, with the following long-limb bypasses: Pylorus preserving Whipple (PPW) (n=2) and bariatric laparoscopic Roux-en-Y gastric bypass (RNYGB) (n=8). Four pts (2 PPW and 2 RNYGB) had a previous failed attempt with other endoscopes, including variable stiffness colonoscopes and standard-push enteroscopes with non-balloon overtubes. Indications: All procedures were carried out with the new Olympus Q180 200cm SBAE. Cannulation and therapy was performed with special enteroscope length accessories supplied by various companies. Indications included: common duct stone (n=1), ampullary stenosis/SOD Type I (n=1), recurrent pancreatitis (n=2), severe right upper quadrant (RUQ) pain with dilated ducts (n=2), chronic pancreatitis (n=2), and PD stent removal (n=2). Results: 8/10 (80%) procedures were successful in reaching the RUQ and assessing the desired duct. Two failures were due to adhesions in one PPW patient and inability to advance beyond the ligament of Treitz in a RNYGB patient. Two diagnostic ERCPs noted a normal cholangiogram in one and extensive pyloric channel ulcer disease in the other. Six therapeutic ERCPs included biliary sphincterotomy (n=1), pancreatic sphincterotomy with stent placement (n=2), biductal sphincterotomy with nasopancreatic drainage (n=1), and pancreatic stent removal (n=2). Complications included a single episode of delayed mild pancreatitis. Both barbless pancreatic duct stents failed to pass after 3 weeks requiring a second SBAE ERCP with successful removal. Experience is ongoing. Conclusions: Single-balloon assisted enteroscopy permitted access to the RUQ in most patients in this initial experience. Diagnostic and therapeutic ERCP was accomplished in all cases where the RUQ was reached. Technical challenges include the front-viewing nature of the enteroscope, the absence of an elevator and the limited selection of therapeutic accessories. Routine per oral ERCP in post-operative long-limb bypass patients should be routinely possible, at least in specialized centers of excellence.

Are there roles for intraductal US and saline solution irrigation in ensuring complete clearance of common bile duct stones?

Persistent small common bile duct (CBD) stones after endoscopic sphincterotomy (EST) and stone extraction may be a nidus for stone growth and could be detected by intraductal US (IDUS). CBD saline solution irrigation may flush out residual stones. Our purpose was to determine the frequency of residual CBD stones after EST and basket/balloon extraction by using IDUS and to assess the effectiveness of saline solution irrigation in clearing remnant CBD stones. Prospective study. General Hospital Singapore. Seventy patients (mean age 62 years, 51% male) were recruited. In the presence of CBD stones, EST and stone extraction were performed, followed by IDUS. If residual stones were detected, a catheter was inserted into the proximal CBD, saline solution irrigation performed, and IDUS repeated. (1) The frequency of residual stones detected by IDUS after EST and basket/balloon extraction and (2) the effect of saline solution irrigation in clearing residual CBD stones. Cholangiogram showed CBD stones in 38 of 70 patients (median 1 [range 1-5], mean size 7.6 mm [range 3.0-12.0 mm]). IDUS showed CBD stones in 32 of 32 with normal cholangiogram (median 2 [range 1-8], mean size 2.6 mm [range 0.9-7.2 mm]). After EST and stone extraction, IDUS showed persistent stones in 28 of 70 (median: 2 [range 1-5], mean size 2.2 mm [range 1.1-4.6 mm]). The CBD was irrigated with a mean of 48 mL of saline solution. Repeat IDUS showed persistent CBD stones in 2 of 70, and these were flushed out by further saline solution irrigation. Single-center study. IDUS detected small residual CBD stones that persisted after EST and basket/balloon extraction. Saline solution irrigation appeared useful in clearing residual small stones.

Small-duct primary sclerosing cholangitis

Patients with cholestatic liver tests and typical histologic features of primary sclerosing cholangitis (PSC) but a normal cholangiogram have been identified as having small-duct PSC. This subgroup of PSC has been less well characterized than the classic large-duct form. Some patients characterized as having small-duct PSC develop cholangiographic features of PSC during follow-up. Three papers published in 2002 on small-duct PSC patients suggested a better prognosis in patients with small-duct PSC than in those with large-duct PSC. However, these studies included a limited number of patients and had a short follow-up. A combined cohort of these patients with a prolonged follow-up recently confirmed these previous observations. However, some patients will suffer from liver-related mortality or will need to undergo liver transplantation. Recurrence of small-duct PSC after liver transplantation has been reported. Cholangiocarcinoma, the most feared complication of PSC, has not been described in a patient with small-duct PSC without progression first to large-duct PSC.

Biliary Disease in Pregnancy With an Emphasis on the Role of ERCP

The incidence of gallstones during pregnancy is estimated to be between 3% and 12%. About one-third of pregnant patients with cholelithiasis become symptomatic and may require surgical intervention. Choledocholithiasis during pregnancy although infrequent usually requires therapeutic intervention. Abdominal ultrasonography is insensitive for the detection of common bile duct stones. Magnetic resonance imaging is not being associated with known adverse effects and seems to be an excellent diagnostic modality in this context. Paramagnetic contrast agents have been associated with increased spontaneous abortion rates and other abnormalities in animals and should only be used when absolutely necessary. Endoscopic ultrasonography is highly accurate for the detection of common bile duct stones and may be useful before consideration of endoscopic retrograde cholangiopancreatography (ERCP) in select patients. The second trimester seems to be the safest time to perform surgery, as organogenesis is complete and the incidence of spontaneous abortion lower. ERCP followed by sphincterotomy and stone extraction is very effective and can be performed safely during all trimesters of pregnancy with a premature delivery rate less than 5%. All efforts to minimize radiation exposure should be undertaken. These include lead shielding and avoiding hard copy radiographs. When possible, category B (such as meperidine) or C drugs only should be used for sedation during pregnancy. Therapeutic ERCP is now the standard of care for treating choledocholithiasis during pregnancy. Endoscopic sphincterotomy for symptomatic patients with normal cholangiograms is controversial. Consideration of ERCP demands a judicious approach, paying careful attention to risks and benefits of intervention.