Partial Common Bile Duct Obstruction Research Articles

Partial Ligation of the Common Bile Duct Results in Reversible Cholestasis in Rats

The animal model of common bile duct ligation is very toxic; therefore, the aim of this study was to establish a new model of obstructive jaundice in rats with partial common bile duct obstruction. Male Sprague-Dawley rats were subjected to a sham operation or partial ligation of bile duct procedure. Serum biochemistry, liver histology, and expression of bile salt transporters were examined after surgery. Serum levels of aspartate aminotransferase, alkaline phosphatase, total bilirubin, and bile acids were significantly increased in the partial bile duct ligation group 3 days after surgery. However, these changes spontaneously normalized within 14 days after surgery in the partial bile duct ligation group compared with the sham group. Bile infarcts, ductular reaction, and abundant hepatocyte turnover were detected exclusively in the partial bile duct ligation group on postoperative day 3. However, these changes dramatically reversed 14 days after surgery. Bile salt transporter expression was significantly decreased at day 3 and gradually recovered in the following 2 weeks. In conclusion, the current rat model of obstructive cholestasis is reversible, representing the clinical characteristics of partial biliary obstruction, and may be used to investigate the effects of various therapeutic strategies on reversible acute cholestasis.

Cystic duct-duodenal fistula: an unusual complication of laparoscopic cholecystectomy

A 47 year-old woman with a past medical history significant for hepatitis C presented 11 days after undergoing a laparoscopic cholecystectomy. The patient complained of acute right upper quadrant abdominal pain associated with nausea and vomiting. The patient denied any history of constipation, diarrhea, bright red blood per rectum, melena, fever, or chills. The patient's admission laboratory values were significant for total bilirubin of 2.0 mg/dL, alkaline phosphatase of 49 U/L, AST of 317 U/L and ALT of 141 U/L with WBC of 10.3 K/CMM. The physical exam was only significant for right upper quadrant tenderness. The patient was afebrile and clinically stable. She was empirically started on IV antibiotics. CT of the abdomen and pelvis revealed surgical clips from the cholecystectomy and a small residual postoperative collection in the gallbladder fossa with no evidence of intra or extrahepatic biliary ductal dilatation. Hospital day two revealed changes in the laboratory values with total bilirubin of 4.4 mg/dL, alkaline phosphatase of 245 U/L, AST of 127 U/L and ALT of 89U/L. The patient subsequently underwent a HIDA scan revealing findings consistent with intrahepatic cholestasis versus partial common bile duct obstruction. The patient underwent an ERCP which revealed extravasation of contrast in the region of the cystic duct with two small filling defects in the common bile duct representing stones. After biliary sphincterotomy, the stones were extracted and a 7 Fr 7cm long straight plastic stent was successfully placed in the common bile duct. The patient was continued on antibiotics. One month later the patient returned for an ERCP to remove the biliary stent and to assess for residual bile duct stones. A single 4mm stone was identified and removed with a balloon from the common bile duct. On completion, a cholangiogram revealed a communication between the cystic duct and the duodenum. This case represents an unusual complication of laparoscopic cholecystectomy. The cytic duct to duodenum fistula was originally unnoticed because of the concomitant cystic duct leak. However, once the leak resolved the fistula became apparent.

Scintigraphic criteria for the diagnosis of obstructive hepatobiliary diseases with Tc-99m IDA.

The purpose of this study is to define the scintigraphic parameters that reliably predict the presence of obstructive hepatobiliary diseases. Gallbladder and intestinal visualization times noted during cholescintigraphy with Tc-99m IDA were compared to functional and morphologic parameters for their ability to accurately diagnose biliary diseases. One hundred and twenty-five normal subjects and 127 patients with five different types of hepatobiliary diseases were studied. Bile pooling in segmental ducts with minimal prolongation of excretion t-1/2 was the feature most commonly seen in partial common bile duct obstruction, and biliary nonvisualization with marked prolongation of excretion t-1/2 was the primary feature of total obstruction. Sclerosing cholangitis showed band constrictions and beading along bile ducts with regional variation in excretion t-1/2, and primary biliary cirrhosis demonstrated normal bile ducts with uniform prolongation of excretion t-1/2. Patients with cholelithiasis showed normal image patterns of the major ducts. Intestinal visualization by 60 minutes was only 46% sensitive and 77% specific with an overall accuracy of 74% in the detection of biliary obstruction. Delayed gallbladder visualization and reduction in ejection fraction were sensitive but nonspecific indicators of biliary disease. We conclude that Tc-99m-IDA imaging is an accurate test for the diagnosis of obstructive hepatobiliary disease provided both quantitative functional and qualitative morphologic parameters are analyzed. Intestinal nonvisualization at 60 minutes alone is not reliable as a sole parameter for the detection of partial biliary obstruction.

Antral Gastrin Cell Hyperfunction Associated with Chronic Pancreatitis

This report describes a patient with antral gastrin cell hyperfunction who also had pancreatic pseudocyts and partial common bile duct obstruction secondary to chronic pancreatitis. A 60-year-old female had a th ree-month h istory of worsening epigastric discomfort with episodes of nausea, vomiting and weight loss. The patient had no history of peptic ulcer disease and no ulcers were demonstrated during diagnostic work-up. Baseline fasting serum gastrins were 715 and 1000 pg/ml [normal 50 to 170 pg/ml). These decreased to 515 pg/ml during an intravenous secretin test and increased up to 2155 pg/ml after a protein meal test. The patient also had chronic pancreatitis, multiple pancreatic pseudocysts and a partial common bile duct obstruction. Truncal vagotomy and antrectomy for antral gastrin cell hyperfunction. Roux-en-Y cystjejunostomy for pancreatic pseudocysts and choledochojejunostomy for common bile duct stricture were performed. Three months after the operation, the patient was symptom-free and fasting serum gastrin levels at one week, two months and three months after the surgery were 11, 40 and 50 pg/ml, respectively.

Common bile duct obstruction: assessment by transcholecystic cholangiography.

Percutaneous transcholecystic cholangiography was performed in 20 patients. Fifteen patients had normal-sized bile ducts on sonograms and computed tomographic scans, and five had partial common bile duct obstruction. Gallbladder pressures were measured in 14 patients. In all cases the intrahepatic and extrahepatic bile ducts were well visualized. Only one clinically significant complication, bile peritonitis, occurred, and it was relieved by inserting a cholecystostomy catheter. Techniques as well as the potential indications for transcholecystic cholangiography are discussed. The authors believe the transcholecystic approach is a useful alternative to transhepatic cholangiography.

Recurrent hemorrhage into the pancreatic duct from a splenic artery aneurysm

We describe a case of upper gastrointestinal hemorrhage secondary to splenic artery aneurysm-pancreatic duct fistula, with associated partial common bile duct obstruction and pancreatitis. The literature is reviewed briefly in order to stress distinctive clinical features and caveats in diagnosis. Angiography is the most definitive diagnostic study; surgical resection is curative.

Intravenous cholangiography: experimental evaluation of the time-density-retention concept.

The time-density-retention concept was evaluated in chronic cholecystectomized bile fistula dogs with normal hepatic function, partial common bile duct obstruction, and hepatic parenchymal disease using either iodipamide or iodoxamate. In all investigated conditions, the maximum biliary iodine concentration was found earlier with iodoxamate than iodipamide but the difference was only significant in partial common bile duct obstruction. In this condition a significant delay in attaining the maximum biliary iodine concentration was found with iodipamide but not with iodoxamate. It is concluded that the time-density-retention concept represents a valid radiographic criterion for the diagnosis of partial common bile duct obstruction in cholecystectomized or cystic duct occluded subjects when iodipamide but not iodoxamate is used as contrast agent.

Hepatobiliary scanning using 99mTc-pyridoxylideneglutamate

Technetium 99m-pyridoxylideneglutamate ( 99mTc-PG) administered intravenously is excreted by hepatocytes into the bile canaliculi and enters the gallbladder through the cystic duct and, consequently, can be used for scanning the hepatobiliary ductal system. A total of 166 patients representing 27 normal subjects, 84 patients referred for investigation of pain in the upper right quadrant of the abdomen, and 55 jaundiced patients were evaluated with 99mTc-PG. In normal human volunteers, the agent reached the liver in five minutes, and the common bile duct, gallbladder, and duodenum within 15 minutes. Satisfactory images of the hepatobiliary tract were obtained using small dosages of 99mTc-PG. The gallbladder was not visualized when the cystic duct was occluded. In the presence of acute cholecystitis, cystic duct obstruction, or in chronic cholecystitis where other roentgenographic studies showed a nonfunctioning gallbladder, there was no concentration of 99mTc-PG in the gallbladder. In partial common bile duct obstruction a distended common bile duct was visualized along with delay in transit of radioactivity into the duodenum. Complete common bile duct obstruction was associated with no radioactivity in either the biliary or the gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of biliary and gastrointestinal tracts. 99mTc-PG scanning proved capable of differentiating between hepatocellular disease and extrahepatic biliary tract obstruction.

Clinical evaluation of 99mTc-pyridoxylideneglutamate for hepatobiliary scanning

Clinical evaluation of hepatobiliary scanning using 99mTc-PG was done in twenty normal volunteers and eighty-three patients with liver and biliary tract disease. Satisfactory images of the biliary tract were obtained using small dosages of this agent. In normal humans, the agent reached the liver in 5 minutes, and the common bile duct, gallbladder, and duodenum in 10 to 20 minutes. The gallbladder was not visualized when the cystic duct was obstructed in patients with acute and chronic cholecystitis. In patients with partial common bile duct obstruction, a distended duct was visualized and there was delay in transit of radioactivity into the duodenum. With complete common bile duct obstruction, no radioactivity was seen in the biliary or gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of the biliary and gastrointestinal tracts. There were no toxic or other untoward effects in any patient.

Marked Alkaline Phosphatase Elevation with Partial Common Bile Duct Obstruction due to Calcific Pancreatitis

This study characterizes a syndrome of partial common bile duct obstruction and marked elevation in serum alkaline phosphatase in 6 male alcoholic patients with calcific pancreatitis. In each patient, a marked elevation in serum alkaline phosphatase was associated with minimal, if any, elevation in serum bilirubin. In all cases, the alkaline phosphatase was hepatic in origin, and intravenous or operative cholangiography showed a dilated common bile duct. Liver biopsy showed canalicular bile stasis in 4 patients and bile duct proliferation in 2 patients. This study demonstrates that calcific pancreatitis may cause partial bile duct obstruction which differentially increases serum alkaline phosphatase without altering bilirubin or bromsulphthalein excretion.

Complications of chronic pancreatis.

Summary: Alcohol-induced chronic pancreatitis has many complications. This man, since chronic pancreatitis first became clinically apparent, has developed diabetes mellitus, steatorrhoea, ascites (pancreatic) with a possible pseudocyst and a peripancreatic abscess, gallstones, partial common bile duct obstruction, gastric and duodenal deformities (due to adjacent pancreatitis, or peptic duodenal ulceration) and hepatic portal cirrhosis. Pulmonary tuberculosis was present at the time of onset of his pancreatitis. The course of his disease is followed illustrating the spectrum of complications which may develop during the course of chronic pancreatitis.