Normal Common Bile Duct Research Articles

Results of a phase I–II study on intraductal confocal microscopy (IDCM) in patients with common bile duct (CBD) stenosis

Confocal endomicroscopy is an emergent technique and allows real optical biopsies in the gastrointestinal (GI) tract. The aim of this study was to evaluate a new intraductal confocal miniprobe in patients with a normal common bile duct (CBD) or with a suspicion of a malignant stenosis (cholangiocarcinoma). Thirty-seven patients (23 males) underwent endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stone removal (7 cases) or bile duct stenosis (30 cases). Intraductal confocal microscopy (IDCM) was performed during the ERCP using a probe-based confocal laser endomicroscopy (pCLE) technique. IDCM was done with the CholangioFlex probe with Cellvizio (Mauna Kea Technologies, Paris, France). The depth of penetration of theCholangioFlex probe was 40-70μm and magnification was 400×. Images were reviewed by an experienced pathologist in GI disease and compared to ERCP findings, CBD biopsies performed during ERCP or EUS, and in 15 patients to the resected specimen (Wipple resection). No complications related to the CholangioFlex insertion occurred after the ERCP. Good images were obtained in 33 patients. Final histology diagnosis was a normal CBD in 7 cases, 23 malignant stenoses (4 ampullary carcinomas, 13 cholangiocarcinomas, and 6 pancreatic cancer), and 7 inflammatory stenoses (4 chronic pancreatitis, 1 stenosis of hepaticojejunal anastomosis, 1 postcholecystectomy CBD stenosis, and 1 primary sclerosing cholangitis). IDCM of a normal CBD showed a thin black band (<20μm), normal vessels (thin and regular), and no visible glands. IDCM of malignant strictures revealed irregular vessels with lack of contrast in the CBD wall, large black band (>20μm), and an aggregate of irregular black cells (black clumps). These aspects were seen in all malignant stenoses and none were seen in benign or normal CBD. The presence of irregular vessels, large black bands, and black clumps seen with confocal laser microscopy enabled prediction of neoplasia with an accuracy rate of 86%, sensitivity of 83%, and specificity of 75%. The respective numbers for standard histopathology were 53, 65, and 53%. This phase I-II study on IDCM showed that IDCM is feasible. This new technique will open a new door for optical biopsy of the CBD.

An Unusual Cause of Double Duct Sign

Question: A 75-year-old man, an opium addict for 30 years, presented with episodes of upper abdominal pain for 6 months. Investigations revealed hemoglobin, 14.6 gm%; TLC, 8600; DLC polymorphs, 65%; lymphocytes, 35%; blood urea, 35 mg/dL; serum creatinine, 1.4 mg/dL; serum bilirubin, 1.6 mg/dL (0.4 mg conjugated and 1.2 mg unconjugated); aspartate aminotransferase, 68 U/L (normal, 14–40); alanine aminotransferase, 78 U/L (normal, 10–40); and alkaline phosphatase, 185 U/L (normal, 38–126). Abdominal ultrasound revealed a dilated common bile duct (CBD) and pancreatic duct (PD). A side-viewing endoscopy showed normal ampulla (Figure A). Radial endoscopic ultrasound (EUS) images are shown in Figures B and C. A hypoechoic area (6.3 × 5.7 mm size) surrounding the lower part of CBD and PD was consistently noted just outside the duodenal wall in the prepapillary area (Figure D; Video 1). What is the diagnosis? What is the cause of this hypoechoic area? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The double duct sign (DDS) consists of simultaneous dilatation of the CBD and PD, usually owing to malignancy involving lower part of CBD and PD. Benign causes include chronic pancreatitis and sphincter of Oddi dysfunction (SOD).1Ahualli J. The double duct sign.Radiology. 2007; 244: 314-315Crossref PubMed Scopus (46) Google Scholar Opiate-induced SOD as a clinical entity has been described in patients with chronic opium addiction (COA).2Sharma S.S. Sphincter of Oddi dysfunction in patients addicted to opium: an unrecognized entity.Gastrointest Endosc. 2002; 55: 427-430Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 3Wu S.D. Zhang Z.H. Jin J.Z. et al.Effects of narcotic analgesic drugs on human Oddi's sphincter motility.World J Gastroenterol. 2004; 10: 2901-2904Crossref PubMed Scopus (56) Google Scholar EUS is useful in the diagnostic evaluation of patients with DDS, especially where side-viewing endoscopy shows no tumor at the ampulla. EUS findings in this patient with COA, who presented with DDS, showed hypertrophy of the prepapillary sphincter, which gave an appearance of a tumor in periampullary area just outside the duodenal wall. EUS was clearly able to show the normal passage of both the CBD and the PD through this hypoechoic area (Video 1). Endoscopic retrograde cholangiography revealed normal CBD at the lower end and endoscopic sphincterotomy (ES) was performed (Video 2). In this case, the prepapillary sphincter was hypertrophied and EUS was helpful in ruling out the hypoechoic sphincter as malignant. Thereafter, the patient was selected for endoscopic retrograde cholangiopancreatography (ERCP) and ES. To summarize, EUS may be useful for evaluation of SOD owing to COA before therapeutic ERCP. Download .mpg (15.85 MB) Help with mpg files Video 1 Download .mpg (7.6 MB) Help with mpg files Video 2

Diameters of the common bile duct in adults and postcholecystectomy patients: A study with 64-slice CT

This study aims to collect data by multidetector computed tomography (MDCT) on the diameter of the normal common bile duct (CBD) and the diameter of CBD after cholecystectomy. In this retrospective study, CBD measurements were performed on axial oblique images, perpendicular to the long axis of the distal CBD. The mean diameter of the normal CBD was measured in 604 patients without cholecystectomy. The patients were divided into 6 groups according to their age. Analysis of variance (ANOVA) was used to compare data obtained from the six age groups. The mean diameter of the CBD of 46 patients who had cholecystectomy was calculated. The results were compared with age matched control group by Student's t test. The largest diameter of CBD ranged from 1.8 to 11.8mm. The mean of the largest diameter of 604 subjects was 4.77 ± 1.81. The diameter of the CBD significantly increased with age. Mean largest CBD diameters of postcholecystectomy subjects (7.28 ± 2.37) were significantly greater than age matched control group. In conclusion the diameter of CBD shows a considerable increase with age. The largest diameter of the CBD is up to 6mm in most of the subjects. An upper limit of 8mm appears reasonable after the age of 50; and an upper limit of 10mm seems appropriate for cholescystectomized subjects.

415a: Results of a Phase II Study on Intraductal Confocal Microscopy (IDCM) in Patients With Common Bile Duct (CBD) Stenosis

Background Confocal endomicroscopy is an emergent technique and allows real optical biopsies in the gastrointestinal (GI) tract. The aim of this study was to evaluate a new intraductal confocal miniprobe in patients with a normal common bile duct (CBD) or with a suspicion of a malignant stenosis (cholangiocarcinoma).

Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED

Objective The diagnosis of cholecystitis or biliary tract disease in children and adolescents is an uncommon occurrence in the emergency department and other acute care settings. Misdiagnosis and delays in diagnosing children with cholecystitis or biliary tract disease of up to months and years have been reported in the literature. We discuss the technique and potential utility of point-of-care ultrasound evaluation in a series of pediatric patients with suspected cholecystitis or biliary tract disease. Methods We present a nonconsecutive case series of pediatric and adolescent patients with abdominal pain diagnosed with cholecystitis or biliary tract disease using point-of-care ultrasound. The published sonographic criteria is 3 mm or less for the upper limits of normal gallbladder wall thickness and is 3 mm or less for normal common bile duct diameter (measured from inner wall to inner wall) in children. Measurements above these limits were considered abnormal, in addition to the sonographic presence of gallstones, pericholecystic fluid, and a sonographic Murphy's sign. Results Point-of care ultrasound screening detected 13 female pediatric patients with cholecystitis or biliary tract disease when the authors were on duty over a 5-year period. Diagnoses were confirmed by radiology imaging or at surgery and surgical pathology. Conclusions Point-of-care ultrasound to detect pediatric cholecystitis or biliary tract disease may help avoid misdiagnosis or delays in diagnosis in children with abdominal pain.

Determination of Diameter and Angulation of the Normal Common Bile Duct using Multidetector Computed Tomography

Background/AimsCommon bile duct stones are associated with the extent of dilation of the common bile duct as well as its angulation. Multidetector computed tomography (MD CT) has a good resolution for the definition of the anatomical features of the common bile duct.MethodsThe multiplanar reformation images of 398 patients that underwent multidetector CT for the diagnosis of disorders not related to the bile duct were examined. The diameter and angulation were categorized by gender and age.ResultsThe average diameter and angulation of the common bile duct was 6.7 mm and 132.6°. There was a statistically significant correlation between age and the common bile duct diameter. The Pearson correlation analysis for age and diameter resulted in a value of 0.415 (p<0.001). And the common bile duct (CBD) diameter in people older than 51 years of age showed a significant difference compared to the subjects younger than 50 years of age (p<0.01). However, the degree of angulation has no correlation with age.ConclusionsWe suggest that CBD diameters in patients more than 50 years of age can be more than 7 mm and be within normal limits.

Direct Pancreatoscopy With an Ultrathin Forward-Viewing Endoscope in Intraductal Papillary Mucinous Neoplasm of the Pancreas

A 75-year-old man presented with jaundice and profound weight loss. Examination revealed icterus and muscle wasting. Laboratory evaluation was notable for levels of serum albumin of 1.5 g/dL, total bilirubin of 13 mg/dL, alkaline phosphatase of 429 U/L, and γ-glutamyl transpeptidase of 120 U/L. Serum amylase and lipase levels were normal. Magnetic resonance cholangiopancreatography (Figure A) revealed a markedly dilated proximal common bile duct (Figure A, A), normal caliber distal common bile duct measuring 8 mm, and a cystic structure in head of the pancreas (Figure A, B) communicating with the main pancreatic duct (MPD) (Figure A, C), suggestive of main duct type intraductal papillary mucinous neoplasm (IPMN).

Hydralazine-Induced Cholestatic Hepatitis

Hydralazine has been widely used for treating hypertension, particularly in patients with renal failure. We report a case on a patient in whom we believe the drug was implicated in an otherwise unexplained disturbance of liver function. A 63-year-old African-American female with medical history of hypertension and end-stage renal disease (on hemodialysis) was admitted to the hospital with epigastric pain and jaundice. The symptoms started about 1 week ago. Initial laboratory tests showed abnormal liver enzymes with elevated conjugated bilirubin and alkaline phosphatase suggestive of cholestatic jaundice. Amylase and lipase were normal. Abdominal ultrasound showed normal caliber common bile duct without evidence of obstruction. Abdominal CT scan does not show any evidence of intra- or extrahepatic biliary ductal dilatation, and no mass lesions were seen in the pancreas. Further blood chemistry showed worsening of liver enzymes and increased bilirubin over the next 2-3 days. Magnetic resonance cholangiopancreatography failed to show any evidence of intra- or extrahepatic biliary ductal dilatation. No other laboratory evidence of cholestatic jaundice was found. Before proceeding for invasive diagnostic procedure, that is, endoscopic retrograde cholangiopancreatography, the patient's drug history was reviewed. She was on hydralazine 75 mg 3 times per day, started 5 months ago. At that time, her liver function tests were normal. As we could not find any other cause of cholestatic jaundice, we attributed this as a side effect of hydralazine. A trial was given by stopping the hydralazine. It was seen that there was significant improvement in the liver function enzymes over the next week. Complete clinical and biochemical recovery occurred over the next 4 weeks. Liver injury after long-term therapy with hydralazine and after short-term therapy with hydralazine (2-10 days) has been described. Hydralazine-induced hepatotoxicity may manifest as hypersensitivity-type injury, mixed hepatocellular injury, acute hepatitis, cholestatic jaundice, or centrilobular necrosis. The Hydralazine-induced cholestatic liver injury seems to be fully reversible. Complete clinical and biochemical recovery occurs after discontinuation of the drug. Also, the differential diagnosis of any patient with hepatocellular injury should include medications. This will prevent unnecessary diagnostic tests.

Spontaneous air in the main pancreatic duct

A 34-year-old lady was referred to us after an episode of acute biliary pancreatitis which was diagnosed three months back, and resolved on conservative treatment. She again became symptomatic with abdominal discomfort after one month. There was no history of vomiting, dyspnea, jaundice, fever, weight loss or anorexia. Her laboratory parameters were: Hb 12 gm, leukocyte count 8600/cmm, S. amylase 350, bilirubin 1.2 mg, and alkaline phosphatase 428 IU/dL; serum protein and transaminase values were normal. CECT of the abdomen revealed air in the main pancreatic duct (PD) (Fig. 1); the duct was normal in caliber. CT also showed multiple fluid collections suggestive of pseudocyst, stone in gall bladder and dilated common bile duct (CBD). She underwent ERCP which showed large periampullary diverticula with normal CBD and normal PD without any extravasations of contrast from PD. She was kept on conservative management for the pancreatic pseudocyst. At six month follow-up, she was asymptomatic; follow-up ultrasound did not reveal air in pancreatic duct but showed the decrease in pseudocyst size to 2.5 cm. Air in the pancreas is frequently reported to be associated with an abscess or a pancreatic fistula but has also been demonstrated in normal pancreatic glands. It has been shown to occur with duodenal obstruction, biliary and pancreatic ascariasis with liver abscesses, pancreatic pseudocyst and acute or chronic pancreatic. 1-4 Our patient was a follow-up case of acute pancreatitis who had presented with pseudocyst and was found to have air in pancreatic duct. In the majority of cases reported in the literature, the air was visualized by US and only in three cases was the air seen at CT abdomen. In our case no air was detected in the biliary tree as had been reported in some of the previously described patients.

Adenoendocrine carcinoma of the accessory papilla of the duodenum: Report of a case

This report describes a very rare case of an adenoendocrine carcinoma of the accessory papilla of the duodenum. A 70-year-old woman was admitted to the hospital complaining of epigastralgia. Gastrointestinal endoscopy showed a protruding tumor with ulceration at the accessory papilla of the duodenum. A biopsy revealed a small-cell carcinoma. Computed tomography showed a highly enhanced tumor in the early phase. No metastatic lesions were shown. Magnetic resonance cholangiopancreatography showed dilatation of the pancreatic duct, but a normal common bile duct. A pyloruspreserving pancreaticoduodenectomy was performed with lymph node dissection. Microscopically, the tumor was a small-cell neuroendocrine carcinoma with adenomatous differentiation. An immunohistochemical analysis showed positive staining for synaptophysin, chromogranin A, CD56, and carbohydrate antigen 19-9. The final diagnosis was an adenoendocrine carcinoma with lymph node metastasis. The postoperative course was uneventful and the patient is now doing well as an outpatient after 14 months of follow-up.

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.

Significant lamotrigine overdose associated with acute pancreatitis

In March 2007, a 24-year{old woman was admitted via the Emergency Department after an act of deliberate self{harm. Five hours prior to admission she had taken 4200 mg of lamotrigine. She denied taking any other medication at the time of this overdose. Her relevant medical history included two previous episodes of mixed overdoses (July 2002 and May 2006), depression and a psychotic episode for which she was treated with mirtazepine 30 mg once daily, lamotrigine 100 mg twice daily and risperidone 2 mg twice daily. At the time of admission she reported a regular intake of two 750 mL bottles of wine per evening, but had no previous history of alcohol{related liver or pancreatic problems. She had drunk two bottles of wine with her overdose. On admission, she was tachycardic, lethargic, dehydrated, showed slurred speech, with cerebellar signs of nystagmus and ataxia. She had no evidence of abdominal tenderness. Arterial blood gas measurements revealed a compensated metabolic acidosis. Full blood count, urea, electrolyte and liver function tests were normal. Her blood alcohol level was 100 mg/100 mL. Paracetamol and salicylate were not detected. A lamotrigine level was not taken because it is not routinely available in our institution. An electrocardiogram showed a sinus tachycardia only. Within 24 hours of admission she complained of upper abdominal pain and vomiting. Serum amylase was 1043 U/L (0–110 U/L). Liver transaminase, full blood count, calcium, glucose, urea and electrolyte levels were within reference ranges. The patient was diagnosed with acute pancreatitis, and at 48 hours achieved a Ranson score of 1 on assessment of severity, predicting a good prognosis, with less than 1% mortality. General supportive treatment was started with intravenous fluid resuscitation, analgesia and antiemetics. Abdominal ultrasound two days after onset of symptoms showed a thickened gall bladder wall, with some surrounding fluid and no evidence of gallstones. Her symptoms as well as amylase levels settled within three days and the patient was discharged five days after the initial overdose. An endoscopic ultrasound of the pancreas was performed six weeks after discharge. This showed a normal gallbladder and common bile duct. The pancreas had no features of chronic pancreatitis and had a normal calibre pancreatic duct. In the 12 months following discharge she was seen twice in the Emergency Department with symptoms and signs consistent with significant alcohol abuse, however on both occasions her amylase was normal.

Orthotopic Liver Transplantion

Purpose: Liver transplantation (LT) has been the curative therapy for patients with Caroli's disease (CD) having recurring episodes of cholangitis, sepsis and biliary stone formation. There have been no reported cases on the recurrence of intrahepatic bile duct complications in patients with CD who underwent LT. We report a patient with CD who developed a recurrence of intrahepatic biliary dilatation and stricture formation 12 years post – LT. Methods: A 49 year old female was diagnosed with CD in 1992. She had right upper quadrant pain, cholestatic liver disease and was found to have intrahepatic ductal dilatation without portal fibrosis but associated with bilateral multiple renal cysts. She underwent LT with Roux-en- Y anastomosis in 1995 after having recuurent cholangitis with septicemia. In 1999, patient presented with elevated alkaline phosphatase and CT abdomen revealed moderately dilated intrahepatic ducts, patent hepatic-portal veins and a normal common bile duct- CBD. In 2007, she presented with cholangitis and cholangiogram showed a stone in the left bile duct with progressive intrahepatic biliary dilatation. The patient underwent PTC with stent placement followed by stone removal. Since then, the patient has had 2 episodes of right upper quadrant pain with elevated alkaline phosphatase, the last being in 03/2008. On both occasions, the patient underwent PTC with stent exchange and the symptoms improved. Recent abdominal MRI is suggestive of worsening of intrahepatic biliary dilatation with no evidence of biliary mass. CA 19-9 always remained normal. The worsening progression of intrahepatic biliary dilatation leading to recurrent hospitalizations for cholangitis has led to the consideration of retransplantation. Results: Conclusion: Caroli's disease (CD) is a nonobstructive segmental dilatation of the intrahepatic bile ducts. Most common variant, Caroli's syndrome involves bile duct dilatation with hepatic fibrosis. Women are predominantly affected; the average age at diagnosis is 22 years. The diagnosis is established by USG, ERCP and MRCP that demonstrate intrahepatic biliary dilatation with a normal CBD. Medical treatment includes antibiotics for bacterial cholangitis and ursodiol for prevention of bile stone formation. LT is successful with high survival rate for 5 year of 90% and 10 year survival rate of 78%. Patients with Caroli's syndrome due to portal fibrosis develop portal hypertension requiring the need for LT. Most patients with Ischemic-related injury present with complaints within the first 6 months of LT. Another possibility could have been the PKHD1 gene mutation causing the recurrent biliary complications. The etiology for recurrent bile duct complications post LT in our patient after 12 years is unclear.

Fasciola Hepatica Causing Acute Pancreatitis Complicated by Biliary Sepsis

Purpose: Although gallstones and alcohol are the most common causes of acute pancreatitis (AP) world-wide, parasites such as ascariasis have been shown to be an important cause in other parts of the world. Methods: We present a case of a patient recently emigrating from Asia found to have a rare parasitic infection causing biliary sepsis in a patient with AP. Results: A 33 year old gentleman presented with a 2 day history of nausea, vomiting, fever, and epigastric pain-which was described as burning and radiating to the RUQ. The patient denied any medical or surgical history, or history of alcohol use. The patient was born and raised in Uzbekistan (former USSR), and moved to the U.S. 2 months prior. Vital signs at admission were significant for a fever of 38 C, and heart rate of 115 beats per minute. Significant findings on physical exam were scleral icterus, and RUQ tenderness. Laboratory findings on admission included a WBC of 16,000/mm3 with a differential including eosinophilia of 11%. Liver enzymes (LFT) were elevated with AST of 282 u/l (range 1–37), ALT of 319 u/l (range 1–40), total bili of 5.4 mg/dl (range 0–1.0), direct bili of 3.8 mg/dl (range 0–0.3) and alk phosphatase of 319 u/l (range 39–120). Serum amylase and lipase were elevated at 636 u/l (range 0–131) and 155 u/l (range 1–52), respectively. Serum calcium and triglyceride levels were normal. Ultrasound findings included thickened gallbladder wall, normal common bile duct (CBD) and no gallstones or sludge was appreciated. As the patient remained febrile with persistently abnormal LFT's, ERCP was performed. ERCP revealed mild intra and extra hepatic biliary dilatation with filling defects in the mid CBD. Sphincterotomy was performed followed by balloon sweep of the CBD. A motile, flat, brown, leaf like parasite was retrieved and sent for pathology. Fasciola hepatica was identified. Triclabendazole was initiated, and the patient rapidly improved and remains well. Conclusion: Manifestations of human fascioliasis depends upon the stage and intensity of the infection. Fasciola hepatica has rarely been shown to cause AP. This case demonstrates the classic presentation of biliary sepsis complicating AP. Clinicians must consider fasciola in the differential diagnosis of AP in patients emigrating from endemic countries, especially Central Asia.Figure

Hepatic Sarcoidosis Mimicking Metastatic Cancer

Purpose: Sarcoidosis is an idiopathic granulomatous disease commonly affecting the lung. Extrapulmonary involvement occurs in 50% of cases and can be the major manifestation of the disease. Methods: Case report. Results: A 40-year-old black man presented with malaise, abdominal pain, jaundice, dark urine, and pruritis of 3 weeks duration. The patient lost 25 lbs and reported intermittent melena. Abdominal exam revealed hepatosplenomegaly. Laboratory values displayed anemia and a predominantly cholestatic pattern of liver associated tests: AP 1789 IU/L, AST 202 IU/L, ALT 113 IU/L, TB 11.2 mg/dl, DB 4.7 mg/dl, Albumin 2.9 and INR 1.2. Hepatitis serologies, AMA, ANA, ASMA, and AFB cultures were negative. ACE was elevated. US displayed hepatosplenomegaly with liver heterogeneity and normal common bile duct. CT further revealed ill-defined masses throughout the liver concerning for diffuse metastatic disease. Endoscopy revealed a 4 mm pre-pyloric gastric ulcer with no bleeding. Biopsy of the ulcer displayed a granuloma. Liver biopsy revealed multiple confluent non-caseating granulomas in the portal and periportal zones consistent with sarcoidosis. Conclusion: Hepatic sarcoidosis covers a broad spectrum from asymptomatic hepatic granuloma formation and slightly deranged liver associated tests to chronic cholestasis, cirrhosis and portal hypertension. Hepatosplenomegaly (15–40%) and abdominal pain (5–15%) are the commonest clinical findings. Constitutional symptoms are rare (5%). Increased serum AP, bilirubin (usually <5 mg/dL) and slightly elevated transaminase levels may be seen. Increased AP can be found in up to 90% of patients with signs of hepatic disease. Hepatomegaly is found on imaging in up to 50% of cases, and may be accompanied by splenomegaly and abdominal lymphadenopathy. Hepatic granulomas are rarely visualized on CT (<5% of patients) and when confluent must be differentiated from neoplastic conditions. Glucocorticoid treatment is first-line therapy for hepatic sarcoidosis, improving symptoms and abnormal laboratory values but generally having no effect on progression of disease. Subclinical GI tract sarcoidosis is rare, seen in 5–10% of patients with systemic sarcoidosis. Symptomatic GI involvement is less frequent. The stomach is most often involved in GI tract sarcoidosis and is typically asymptomatic. Ulcerative gastric sarcoidosis occurs with mucosal infiltration by granulomatous inflammation. This typically occurs in the antrum, pylorus and lesser curvature. Epigastric pain is the most common symptom of gastric sarcoidosis occurring in 75% of cases and 25% of patients with GI tract sarcoidosis have signs of upper GI bleeding. Our case highlights rare but important manifestations of sarcoidosis.

Successful Diagnosis and Management of Biliary Cast Syndrome in a Liver Transplant Patient Using Single Operator Cholangioscopy

Purpose: Biliary cast syndrome is an unusual complication of orthotopic liver transplantation (OLT) with serious clinical implications. Biliary cast formation is usually associated with biliary strictures and/or hepatic ischemia. Surgical management is the mainstay of treatment. Endoscopic techniques have been recently described in the successful removal of biliary casts. We report a post OLT patient who underwent successful endoscopic removal of biliary cast using single operator cholangioscopy. Our patient is a 68 year-old male with history of OLT seven months before for hepatitis C induced cirrhosis who came for a follow up visit. He had no complaints and physical exam was normal. He had cholestatic liver enzyme elevation (Alkaline phosphatase 580 IU/L, Total bilirubin 2.3 mg/dl) with normal aminotransferases. Hepatitis C RNA was undetectable. Ultrasound demonstrated normal common bile duct (CBD) diameter with normal Doppler flow. Liver biopsy showed no rejection with suggestion of cholestasis. Endoscopic retrograde cholangiopancreatoscopy (ERCP) was performed and cholangiogram showed multiple linear filling defects in the common hepatic duct (CHD) proximal to the anastomosis with extension into the intrahepatic system. After failure of the balloon to remove the filling defect, a single-operator choledochoscope was passed into the CHD for diagnostic and possible therapeutic purposes. A dark brown tubular structure was seen resembling a cast of the bile duct. Using a basket, the distal aspect of the cast was secured and a 6 cm long cast was successfully removed in a single piece. (Image) Cholangiogram showed improvement with excellent biliary drainage both fluoroscopically and endoscopically. Liver function tests have subsequently normalized and the patient remains normal with a follow period of 10 months without recurrence. In conclusion, Biliary cast syndrome is a rare complication of OLT which should be thought of when patients present with cholestatic liver enzyme elevation usually within the first year of transplant. Single operator cholangioscopy provides a safe means of diagnosing and treating patients with Biliary cast syndrome particularly in cases with intrahepatic duct casts where surgery or percutaneous techniques are often required. Methods: N/A Results: N/A Conclusion: N/A

Focal pancreatitis mimicking pancreatic mass: magnetic resonance imaging (mri)/magnetic resonance cholangiopancreatography (mrcp) findings including diffusion-weighted mri

Focal pancreatitis (FP) is a confined inflammation that mimics a pancreatic mass. Its imaging diagnosis is important to avoid unnecessary procedures. To describe the spectrum of magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) and diffusion-weighted MRI (DWI) findings of focal pancreatitis mimicking pancreatic masses. Findings of MRI/MRCP including DWI with a b value of 0 and 600 s/mm(2) in 14 patients with pancreatic masses on MRI were retrospectively reviewed and compared to normal pancreas in 14 patients as a control group. FP revealed hypointense signal intensity (SI) (3/14), hypo- to isointense SI (7/14), or isointense SI (4/14) on T1-weighted images, and hypointense SI (1/14), isointense SI (5/14), iso- to hyperintense SI (7/14), or hyperintense SI (1/14) on T2-weighted images compared to remaining pancreas (RP). MRCP images revealed dilatation of the common bile duct (CBD) and main pancreatic duct (MPD) (5/14), dilatation of the MPD only (3/14), dilatation of the CBD only (3/14), and normal MPD and CBD (3/14). Both FP and RP revealed three types of time-signal intensity curves: 1) rapid rise to a peak, with a rapid decline (FP=2, RP=4), 2) slow rise to a peak, followed by a slow decline (FP=5, RP=4), and 3) slower rise to a peak, with a slow decline or plateau (FP=7, RP=6). Mean apparent diffusion coefficient (ADC) values for FP and RP were 2.09+/-0.18 and 2.03+/-0.2 x 10(-3) mm(2)/s, respectively. ADC values of FP and RP revealed no significant difference. The spectrum of imaging findings of focal pancreatitis on MRI/MRCP including DWI was described. Findings of FP were not distinctive as compared to the remaining pancreas.

Histologic and Immunohistochemical Changes in the Stented Common Bile Duct

Many patients with pancreatic carcinoma have stent placement for biliary obstruction before resection. Stent-associated atypia, found in common bile duct (CBD) margins at the time of resection, may be confused with malignancy. We evaluated histologic and immunohistochemical changes in CBD margins from resection specimens for pancreatic carcinoma. Histologic findings in CBDs, including ulcer and inflammation; epithelial metaplasia, atypia, and gland complexity; and increased wall thickness, nerve entrapment, and smooth muscle content, were compared in 30 stented and 31 nonstented CBD margins from pancreaticoduodenectomies for carcinoma and 13 normal CBDs from autopsy material. The proliferation index was calculated for stented and nonstented CBDs after Ki-67 immunohistochemical staining. Immunostaining for Ki-67, p53, and c-erbB-2 was performed in stented CBDs and corresponding carcinomas. All the histologic changes occurred more frequently in stented and nonstented CBD margins from carcinoma patients than in normal CBDs. Stented CBDs had significantly increased epithelial changes and Ki-67 proliferation rate as compared with nonstented CBDs. The stented CBDs had significantly less p53 and c-erbB-2 expression as compared with corresponding pancreatic carcinomas. Caution should be applied when interpreting atypia in CBD margins from patients with a history of CBD stenting. Changes found in stented CBDs are characteristic, and in most cases can be distinguished from malignancy. In difficult cases, immunohistochemistry may be useful.

Role of Endoscopic Ultrasonography in Prevention of Unnecessary Endoscopic Retrograde Cholangiopancreatography

The purpose of this study was to evaluate the impact of substituting endoscopic ultrasonography (EUS) for endoscopic retrograde cholangiopancreatography (ERCP) in cases of a low to intermediate risk for choledocholithiasis. During a 16-month period, patients who were referred for suspected choledocholithiasis, biliary colic, or acute biliary pancreatitis on the basis of alterations in liver enzyme values with or without gallstones seen on transabdominal ultrasonography were included. Endoscopic ultrasonography was performed for all patients. Patients with common bile duct stones underwent ERCP. Cholecystectomy was recommended in all patients with symptomatic gallstones. Cases were followed for 12 months. A total of 150 patients were included. Choledocholithiasis was diagnosed by EUS in 39 patients (26.0%) and was confirmed by ERCP in 30 (77.0%). Fifty-one patients had a normal common bile duct, and follow-up for 12 months showed no abnormalities except in 1 patient. Cholecystectomy without ERCP was recommended for the remaining 60 patients who had symptomatic gallstones or sludge. Endoscopic retrograde cholangiopancreatography was avoided by this approach in 110 patients (73.3%). In a low to intermediate risk for choledocholithiasis, EUS can preclude the need for ERCP in most cases.

Linear Vs Radial Optical Coherence Tomography in the Visualization of the Normal Common Bile Duct: An Experimental Study

Background: Radial optical coherence tomography (ROCT) permits high-resolution, real-time, infrared-generated radial imaging of tissue. Resolution is approximately 10 mm and the penetration depth is about 1.5 mm. Only few studies are so far published on the use of OCT in the investigation of the common bile duct (CBD). Recently, a new linear-array OCT (LOCT) has been proposed only for experimental use; compared with ROCT, LOCT permits a higher resolution whit a similar depth of penetration. Aim: To evaluate the accuracy of LOCT in the detection of the normal CBD layers' structure and to compare ROCT and LOCT images of the CBD wall structure.