Introduction: Primary lymphoma of the ampulla of Vater is an exceptionally rare entity, with most reported cases being low-grade B-cell lymphomas in adults. Diffuse Large B-Cell Lymphoma (DLBCL) at this site is markedly aggressive and exceedingly uncommon in the pediatric population. Case Presentation: An 11-year-old male presented with obstructive jaundice. Abdominal ultrasound revealed a dilated gallbladder. Endoscopic Retrograde Cholangiopancreatography (ERCP) identified a fungating mass at the ampulla of Vater, causing significant biliary dilation. Histopathological and immunohistochemical analysis of biopsy samples (positive for LCA and CD20, negative for CD3) confirmed the diagnosis of DLBCL. Staging CT scan showed localized disease with cervical lymphadenopathy. The patient was managed with biliary stenting and systemic immunochemotherapy (R-COP protocol). Following an episode of hepatotoxicity, doxorubicin was introduced. Post-treatment imaging showed an excellent therapeutic response, and the patient was scheduled for consolidative radiotherapy. Conclusion: This case underscores that lymphoma, though rare, should be considered in the differential diagnosis of obstructive jaundice even in children. A multimodal approach involving ERCP with biopsy and imperative immunohistochemistry is crucial for an accurate diagnosis to avoid unnecessary surgery. Management centered on immunochemotherapy, with adjuncts like biliary decompression and radiotherapy, can lead to successful outcomes in pediatric ampullary DLBCL.

IntroductionIgG4-related disease (IgG4-RD) AIP type 1 is a chronic fibro-inflammatory disorder affecting the pancreas and biliary system. While corticosteroids remain the mainstay of treatment, prolonged use may lead to complications including pancreatic insufficiency and secondary diabetes mellitus.Clinical CaseA 62-year-old male presented in 2021 with obstructive jaundice. Imaging showed a distal biliary stricture, and ERCP with stenting was performed. Elevated serum IgG4 levels (>3× upper limit of normal) and biopsy confirmed IgG4-RD with pancreatobiliary involvement. He responded to corticosteroids but experienced multiple relapses, necessitating repeated courses. He declined steroid-sparing agents. The patient developed new-onset diabetes during treatment, with HbA1c values ranging from 7.0% to 9.2%, and GMI of 8.7%. Notably, his glycemic control improved following the initiation of steroids but worsened upon tapering, with HbA1c rising to 8.5%. After steroid therapy was reinstated, his HbA1c decreased again to 6.9%. He was managed with insulin glargine and lispro and monitored with Freestyle Libre 2. Concurrent pancreatic exocrine insufficiency was confirmed (low fecal elastase), and pancreatic enzyme replacement therapy (PERT) was started.This case illustrates the metabolic impact of chronic corticosteroid use in IgG4-RD, particularly the development of type 3c diabetes mellitus (T3cDM). Studies suggest diabetes improves in 50–60% of AIP patients if treated early; however, repeated steroid exposure and pancreatic atrophy may lead to permanent dysfunction. Multidisciplinary management is essential.ConclusionEarly detection and individualized therapy in IgG4-RD are key to reducing endocrine and exocrine complications. Recognizing T3cDM as a potential consequence enables timely intervention and improved outcomes.

BACKGROUND Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms primarily originating in the stomach or small intestine. Duodenal GISTs are particularly uncommon, accounting for only a small fraction of GIST cases. These tumors often present with nonspecific symptoms, making early detection challenging. This case discusses a duodenal GIST misdiagnosed as pancreatic cancer due to obstructive jaundice. CASE SUMMARY A 40-year-old male with jaundice and abdominal symptoms underwent imaging, which suggested a malignant periampullary tumor. Preoperative misdiagnosis of pancreatic cancer was made, and surgery was performed. Postoperative histopathology confirmed a duodenal GIST. The role of artificial intelligence in the diagnostic pathway is explored, emphasizing its potential to differentiate between duodenal GISTs and other similar conditions using advanced imaging analysis. CONCLUSION Artificial intelligence in radiomic imaging holds significant promise in enhancing the diagnostic process for rare cancers like duodenal GISTs, ensuring timely and accurate treatment.

ABSTRACTPatients with poor Eastern Cooperative Oncology Group performance status (ECOG PS) ≥ 3 may be considered for systemic chemotherapy when the decline is driven by reversible tumour‐related factors, but assessing reversibility is often difficult, and some patients ultimately receive best supportive care. We report the case of a 76‐year‐old man with extensive‐stage small cell lung cancer (SCLC) whose condition declined to PS 3 due to obstructive jaundice from pancreatic metastasis and a painful femoral fracture. Biliary stenting improved hepatic function; however, after the first cycle of carboplatin and etoposide, the femur fractured completely, requiring bipolar hemiarthroplasty. Postoperatively, PS improved, enabling the continuation of chemotherapy with carboplatin, etoposide and atezolizumab. Imaging demonstrated regression consistent with partial response, and PS improved to 1. This case emphasises that repeated PS assessment and multidisciplinary management of reversible conditions, including obstructive jaundice and a pathological fracture, can facilitate systemic therapy in poor‐PS SCLC.

Mirizzi Syndrome is a rare complication of long-standing cholelithiasis, characterized by extrinsic compression of the common hepatic duct by an impacted gallstone in the cystic duct or Hartmann's pouch. Its preoperative diagnosis remains challenging due to its mimicry of malignant biliary obstruction, and its management often requires a complex, multi-modal approach. The case of a 66-year-old female presented with multiple comorbidities who presented with obstructive jaundice and was ultimately diagnosed and treated for Type II Mirizzi Syndrome. This case highlights the critical role of endoscopic retrograde cholangiopancreatography (ERCP) in both diagnosis and initial management, the potential for complications, and the necessity for a tailored surgical strategy in high-risk patients. Mirizzi Syndrome, first described by Pablo Luis Mirizzi in 1948, is an uncommon sequela of chronic cholelithiasis, with an estimated incidence of 0.7-1.4% in patients undergoing biliary surgery. It occurs when a gallstone becomes impacted in the cystic duct or infundibulum of the gallbladder, leading to chronic inflammatory changes, fistula formation, and mechanical obstruction of the common hepatic duct. The condition is classified using the Csendes classification: Type I involves external compression of the common hepatic duct without a fistula, while Types II-V involve the presence of a cholecystobiliary fistula of varying sizes. The clinical presentation is often insidious and non-specific, featuring jaundice, right upper quadrant pain, and weight loss, which can be mistaken for pancreaticobiliary malignancies. Accurate preoperative diagnosis is crucial for surgical planning but is often achieved only intraoperatively due to overlapping radiological features with other pathologies. Management is primarily surgical; however, the approach must be highly individualized, considering the patient's comorbidities, the extent of inflammation, and the presence of a fistula. Endoscopic intervention with ERCP plays a vital role in preoperative biliary decompression and stenting, facilitating a safer subsequent surgical procedure. The objective of this case report is to illustrate the diagnostic journey, interdisciplinary management, and successful treatment of a complex case of Type II Mirizzi Syndrome in a patient with significant cardiopulmonary comorbidities. We aim to emphasize the importance of a high index of suspicion, the utility of advanced endoscopic techniques, and the adaptation of surgical techniques to minimize morbidity in high-risk surgical candidates.

Abstract Aim This study aimed to evaluate the clinical outcomes and implications of prolonged waiting times for elective cholecystectomy, focusing on complication rates, healthcare utilization, and the association with wait duration. Method A retrospective analysis was conducted on 697 patients listed for elective cholecystectomy. Data were collected on the duration of waiting time, incidence of gallstone-related complications, hospital admissions, and the need for additional diagnostic or interventional procedures. Statistical analysis was performed using the chi-square test to assess associations between waiting time and clinical outcomes, with significance set at p < 0.05. Results The waiting time ranged from 0 to 2943 days, with a mean of 801.3 days. A total of 94.7% of patients developed complications while awaiting surgery. The most frequent complications were biliary colic (77.6%), acute cholecystitis (43.2%), obstructive jaundice (22.7%), and gallstone pancreatitis (7.6%). Of those with complications, 64% required hospital admission. A significant association was observed between longer waiting times and the need for hospital admission (p = 0.001), ultrasound (p = 0.001), MRCP (p = 0.003), and ERCP (p = 0.001). No significant association was found between waiting time and overall complication rate (p = 0.297) or CT utilization (p = 1.000). Conclusions Prolonged waiting for cholecystectomy is associated with a high burden of complications and increased healthcare resource utilization, particularly hospital admissions and advanced imaging or interventions. Strategies to reduce surgical waiting times may significantly improve patient outcomes and decrease system strain.

Abstract Aim With an aging population, we are treating increasing numbers of elderly patients for acute gallstone disease. The gold standard treatment for gallstones remains a cholecystectomy however this may not be suitable for patients who are frail or co-morbid. We present the 10-year follow up data of our 2019 audit, assessing the management of acute gallstone pathology in an elderly cohort. Method 75 patients (aged >80 years) who were admitted between 2015-2018, with acute gallstone disease, at a single district general hospital, were included in the original audit. 1 patient was lost to follow-up therefore excluded from the re-audit. Patient data was collected from CERNER and analysed using Microsoft Excel. Results 74 patients were included in the re-audit. 46% of patients were female and 54% male. 34/74 (46%) patients were admitted with cholecystitis and 40/74 (54%) patients with ascending cholangitis, obstructive jaundice or pancreatitis. 34/74 patients were treated with antibiotics only. 40/74 patients were treated with intervention in the form of ERCP (24), cholecystostomy (5) and cholecystectomy (11). Of those patients discharged, the average number of days from death to discharge was greater in the intervention group (1157d) than antibiotics (837d) but was not significant (p=0.09). There was a higher number of deaths due to gallstone disease in the antibiotic group (10/34) compared to the intervention group (5/40). In total 20% of patients died from gallstone disease. Conclusions In total, 1 in 5 patients died from gallstone disease. Patients that underwent intervention had longer survival times and lower mortality attributed to gallstone disease.

Comparative Diagnostic Accuracy of Ultrasonography and Magnetic Resonance Cholangiopancreatography (MRCP) in the Evaluation of Obstructive Jaundice: A Prospective Study in Western India

Abstract Background : The ampulla of Vater carcinoma is a rare gastrointestinal malignancy but has a better prognosis than pancreatic cancer. Severe malnutrition is common in patients with gastrointestinal cancer and worsens clinical outcomes. Objective: To report the implementation of structured perioperative nutrition therapy in a severely malnourished patient with carcinoma of the ampulla of Vater. Methods: Case report of a 51-year-old woman with severe malnutrition and obstructive jaundice, who underwent a Whipple procedure . Nutritional status assessment was performed using Subjective Global Assessment (SGA), anthropometry, and hand grip strength (HGS). Perioperative nutritional therapy was carried out in stages, with clinical and laboratory monitoring. Results: Nutrition therapy was started preoperatively with the ERAS method and continued gradually postoperatively through enteral and parenteral routes, until the patient was able to accept a full oral diet and vitamin supplementation. The target energy of 1840 kcal and protein 78 g/day was achieved within 7 days. Clinical status and physical function improved during treatment. Conclusion: Appropriate perioperative nutritional therapy supports metabolic recovery, improves nutritional status, and enhances clinical outcomes in patients with advanced gastrointestinal cancer undergoing major surgery. Keywords : severe malnutrition, ampullary carcinoma , perioperative nutritional medical therapy, Whipple procedure

Pancreatic malignancy is typically associated with advanced age, with the highest incidence occurring globally in the 6th to 7th decade of life and a higher prevalence in men than women. We present a case of pancreatic adenocarcinoma in a 19-year-old female who presented with obstructive jaundice complicated by biliary sepsis, septic shock, and severe acute respiratory distress syndrome (ARDS). Management involved initiating broad-spectrum antibiotics and performing percutaneous transhepatic biliary drainage (PTBD) for source control. With gradual improvement, she was weaned off vasopressor and ventilator support and subsequently extubated. Magnetic resonance cholangiopancreatography (MRCP) revealed an ulcer proliferative growth, prompting endoscopic retrograde cholangiopancreatography (ERCP) with biopsy, which confirmed moderately differentiated adenocarcinoma of the pancreas. Pancreatic cancer, particularly ductal carcinomas, are rare in younger individuals, often leading to underappreciation of their clinical features and treatment among physicians. This case emphasizes the importance of considering malignancy in young patients presenting with pancreatic biliary sepsis. High suspicion warrants MRCP, and if malignancy is suspected, ERCP with histopathology should be performed for early diagnosis and intervention to impede disease progression.

Aim . To evaluate antegrade biliary decompression as part of the multimodal treatment of patients with obstructive jaundice caused by colorectal cancer metastases. Materials and Methods . The study included 85 patients (mean age 60.7 ± 11.7 years) with obstructive jaundice caused by metastatic colorectal cancer. The mean serum bilirubin level at admission was 297.99 ± 158.99 (35.1–785.2) µmol/L, and the duration of jaundice was 17.54 ± 13.43 (3–90) days, which precluded initiation or continuation of systemic therapy. Prior to the onset of jaundice, patients had received 1.36 ± 1.36 (0–5) lines of chemotherapy and 11.52 ± 12.10 (0–63) treatment cycles. All patients underwent antegrade biliary drainage: external (n = 7), external–internal suprapapillary (n = 60), or modified external drainage (n = 18). Results . Clinical success of antegrade biliary decompression (reduction of bilirubin <40 µmol/L) was achieved in 48 patients (56%). Subsequent chemotherapy was administered to 29 patients (34.15%); 19 patients did not receive chemotherapy due to severe clinical condition. Complications occurred in 14.1% of cases, most commonly drain dislodgement. One-year survival among patients who received systemic anticancer therapy after decompression was 34% (n = 10), and 8.9% (n = 5) among those who did not. Age >66 years, bilirubin >400 µmol/L, and impaired hepatic protein synthesis function were statistically significant independent negative predictors of receiving systemic therapy after decompression. The associated risk ratios ranged from 41.7% to 100%. Conclusion . Antegrade biliary drainage in its various modifications is an effective method of biliary decompression that enables initiation or continuation of systemic therapy in patients with colorectal cancer metastases. Decisions regarding the indication and type of drainage should be made by a multidisciplinary team using a multifactorial assessment of the condition and prognosis of patients.

This clinical case report provides a step-wise description of diagnostic evaluation and management of suspected hepatocellular carcinoma complicated by recurrent choledocholithiasis, suppurative cholangitis, and obstructive jaundice. The report focuses on the difficulty of early diagnosis as the tumor mimics inflammatory changes and the clinical presentation is not specific. The diagnostic role of alpha-fetoprotein and limitations of imaging modalities such as ultrasound and MRI are discussed. In addition to the diagnostic challenges of complicated hepatocellular carcinoma, the case highlights the importance of a multidisciplinary approach and includes a brief literature overview.

The 2024 Kyoto guidelines for the management of intraductal mucinous neoplasms (IPMNs) build on previous guidelines that consider worrisome features (WF) and high-risk stigmata (HRS) to recommend surveillance or resection. These new guidelines have not yet been validated. Patients undergoing pancreatectomy for an IPMN at an academic medical center between 2012 and 2023 were included. IPMNs were categorized as low-grade dysplasia (LGD), high-grade dysplasia (HGD), or invasive carcinoma (IC). Preoperative imaging was used to determine HRS and WF in accordance with the 2024 Kyoto guidelines. We compared IPMNs with LGD to those with HGD or IC using univariate analyses and evaluated logistic regression models with c-statistics. Of 211 patients, 84 (40%) had LGD, 49 (23%) had HGD, and 78 (37%) had IC. Among HRS, obstructive jaundice (p = 0.004), pancreatic duct ≥ 10mm (p < 0.001), and suspicious or positive cytology (p < 0.001) were significantly associated with HGD/IC. An increasing number of HRS were associated with higher rates of HGD/IC. Among WFs, an abrupt change in the caliber of pancreatic duct with distal pancreatic atrophy (p = 0.001) and cystic growth ≥ 2.5mm/year (p = 0.033) were significantly associated with higher rates of HGD/IC. Increasing numbers of WFs were also associated with higher rates of HGD/IC. The 2024 Kyoto model showed improved discrimination (area under the curve [AUC] = 0.849) compared with the 2017 Fukuoka model (AUC=0.780, p = 0.06). The risk of HGD/IC in IPMNs increased in a stepwise fashion as the number of WFs increased. The 2024 guidelines represent an advancement over the 2017 guidelines, notably with the inclusion of suspicious cytology as an HRS.

Biliary atresia (BA) is a rare condition in newborns characterised by inflammation and obliteration of bile ducts, leading to cirrhosis. Early diagnosis and treatment through Kasai portoenterostomy are crucial for native liver survival. While diagnostic methods include clinical assessment, laboratory tests and imaging, no non-invasive test can definitively rule out BA. Therefore, laparotomy with cholangiography remains the gold standard for diagnosis. This study assesses the feasibility, safety and accuracy of endoscopic retrograde cholangiopancreatography (ERCP) for diagnosing BA in newborns. The single-center study was conducted at the University Hospital Tübingen. The study included infants with neonatal cholestasis and suspected BA scheduled for ERCP from 2011 to 2023. We identified 60 jaundiced infants with suspected BA scheduled for diagnostic ERCP with a median age of 50 days. Endoscopy was technically feasible in 58/60 children. In 23 of 58 cases, the bile ducts could not be visualized, suggesting BA. Normal bile duct anatomy was visualized in 35/58 patients, and BA was ruled out. The sensitivity was 100%, the specificity was 92.1%, the negative predictive value was 1.0, and the positive predictive value was 0.87. We did not observe any significant complications post-ERCP (in particular, no bleeding, perforation or pancreatitis). However, in one case (1/60; 2%), protracted weaning after general anesthesia occurred.Conclusions: ERCP is a safe, effective and reliable tool for excluding BA in jaundiced infants. ERCP’s integration into the diagnostic algorithm can reduce the burden of surgical diagnostic procedures and enable early diagnosis and portoenterostomy, thereby improving transplant-free survival.What is known – What is new:• Biliary atresia (BA) is the leading cause of obstructive jaundice in neonates, requiring early surgical intervention for optimal outcomes.• Current diagnostic approaches are multimodal but lack a definitive, non-invasive method to exclude BA.• This study demonstrates that ERCP is not only technically feasible in infants as small as 2.6 kg but also highly reliable in excluding BA with 100% sensitivity, 92.1% specificity and a negative predictive value of 1.0.• ERCP is a key diagnostic tool for early exclusion of BA, offering greater diagnostic precision than ultrasound, liver biopsy, or laboratory parameters. Graphical

Fascioliasis hepatis complicated by obstructive jaundice is a rare but clinically challenging form of parasitic infection of the hepatobiliary system, associated with a high risk of diagnostic errors and severe complications. Therefore, the choice of appropriate surgical tactics with a focus on minimally invasive techniques is of particular importance. The aim of this study was to evaluate the efficacy of endoscopic diagnostic and treatment methods for obstructive jaundice of parasitic origin caused by Fasciola hepatica. Materials and Methods. In 2023, 28 patients with bile duct obstruction caused by Fascioliasis hepatis were treated at the Endomed Clinic (Fergana, Uzbekistan). All patients underwent early endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic and therapeutic purposes, followed by endoscopic papillosphincterotomy and parasite removal. Results. In all cases, biliary obstruction was eliminated and clinical manifestations of obstructive jaundice regressed. The average hospital stay was 4.7±1.4 days. Open surgery was not required. Conclusions: Endoscopic minimally invasive techniques are an effective and safe treatment for obstructive jaundice of parasitic origin, reducing hospital stay and the risk of postoperative complications.

Malignant hilar biliary obstruction (MHO), most commonly caused by cholangiocarcinoma, is an aggressive condition with a poor prognosis. Because most patients with MHO are unsuitable for primary surgical resection at presentation because of advanced age or comorbidities, palliative biliary drainage is essential to relieve obstructive jaundice and improve the quality of life. Endoscopic drainage has become the preferred palliative approach, with the choice between plastic and metal stents depending on subsequent therapeutic plans, such as systemic chemotherapy or local ablative therapies. Among biliary stents, self-expandable metal stents (SEMSs) are widely used, typically in their uncovered form. However, unlike plastic stents, uncovered SEMSs cannot be removed once deployed, and endoscopic revision is technically challenging. To improve stent patency and facilitate removability, covered SEMSs (CSEMSs) were developed, and are now commonly used in distal malignant biliary obstruction. Nevertheless, in advanced MHO, the primary use of CSEMSs remains controversial. This review summarizes recent endoscopic strategies for advanced MHO, the evolution of CSEMSs, their clinical outcomes, current limitations, and future directions.

Background: Obstructive jaundice is a common condition in daily clinical practice. Given the severity of its potential complications, prompt management and resolution are essential. Percutaneous biliary drainage is a viable therapeutic option. The aim is to evaluate the effectiveness of percutaneous biliary drainage in reducing bilirubin levels and providing symptomatic relief in patients with obstructive jaundice treated at Hospital Nacional Posadas between 2019 and 2024. Methods: A retrospective review was conducted using the database of Hospital Nacional Prof. A. Posadas. All patients diagnosed with obstructive jaundice (total bilirubin ≥2 mg/dL) who underwent percutaneous biliary drainage between June 2019 and May 2024 were included (n = 118). Data collected included age, sex, comorbidities, procedures, underlying cause, complications, laboratory results, and symptomatic improvement. Results: A total of 118 patients underwent percutaneous biliary drainage. Of these, 58 (49.1%) were female and 60 (50.8%) were male. The mean age was 60.43 years. The average baseline total bilirubin level was 15.44 mg/dL. Clinical presentation included jaundice (86.44%), fever (20.33%), and pain (55.08%). At 72 hours postprocedure, 59.32% of patients experienced a 50% reduction in bilirubin levels, and 70.33% reported symptomatic relief. The average total bilirubin at discharge was 8.6 mg/dL. Procedure-related complications occurred in 5.08% of patients, the most common being hemorrhage (2.54%). A second drainage procedure or catheter replacement was necessary in 31.34% of cases, and 15.25% required an additional intervention (endoscopic retrograde cholangiopancreatography or surgery) to achieve adequate bilirubin reduction. Conclusion: In our series, percutaneous biliary drainage proved to be an effective and safe method for reducing bilirubin levels and providing symptomatic relief, with an acceptably low complication rate.

Intraductal papillary neoplasm of the bile duct.

Epidemiology and outcomes of patients of gallbladder cancer presenting with obstructive jaundice: experience from a university hospital in a high incidence area in North India

A 50s male was diagnosed with multiple hepatocellular carcinomas(HCCs), tumor thrombus in the right atrium, and multiple lung metastases. Because the HCCs were unresectable, chemotherapy was planned. However, the patient developed obstructive jaundice 20 days after the first visit, before chemotherapy could be initiated. Immediate treatment was thought necessary to prevent HCC progression. Because the Child-Pugh score was A(6 points)on the first visit, lenvatinib was administered without drainage. The jaundice improved after 10 days of treatment, and computed tomography revealed shrinkage of the HCC and improvement in intrahepatic bile duct dilatation 14 days later. The lenvatinib treatment was continued thereafter, and jaundice did not recur. The patient died 9 months later. This report highlights the usefulness of lenvatinib without drainage in patients with obstructive jaundice due to HCC when urgent treatment is necessary and liver function is well-preserved.