Proximal Common Bile Duct Research Articles

Aetiological Spectrum of Pancreaticobiliary Diseases in Adult Nigerians on Magnetic Resonance Cholangiopancreatography.

Imaging is vital for assessing pancreaticobiliary diseases. The aim of the study was to investigate the spectrum and pattern of pancreaticobiliary diseases in adult Nigerians using magnetic resonance cholangiopancreatography (MRCP). This was a retrospective, descriptive cross-sectional study. The electronic radiological records of 110 adult Nigerians who had undergone MRCP were reviewed. The MRCP images were evaluated for bile duct dilatation, intraluminal filling defects, strictures, calculi, and other abnormalities. There were 45 males (40.9%) and 65 females (59.1%) aged 18-83 years, with a mean age of 51.93 ± 15.22 years. Jaundice (59.1%) and right hypochondrial pain (31.8%) were the most common presenting complaints. Gallstones (32.7%), common bile duct strictures (15.5%), choledocholithiasis (11.8%), pancreatic head carcinoma (10.9%), and gallbladder carcinoma (2.7%) were the most frequent abnormalities. There was biliary obstruction in 56.4% of participants, mostly at the distal and proximal common bile duct. Other findings include hepatomegaly (23.6%), hepatic cysts (6.4%), hepatic steatosis (0.9%), duodenal wall thickening (1.8%), and ascites (5.5%). MRCP was normal in 25 (22.7%) participants. Gallstones were the predominant pathology of the various pancreaticobiliary diseases, while Pancreatic head and gallbladder carcinoma were the most common malignant diseases.

OGBN V02 Robotic common bile duct clearance

Abstract Background A 44-yar old male patient presented with painful obstructive jaundice and bilirubin of 127 μmol/L. A Contrast Enhanced Computed Tomography (CECT) revealed dilated biliary tree as a result of obstructing stone in the proximal common bile duct (CBD). The patient underwent an Endoscopic Retrograde CholangioPancreatography (ERCP) and sphincterotomy which demonstrated pus in the bile duct, but also a stone impacted in the common hepatic duct which could not be extracted endoscopically. Therefore, a 7Fr pigtail stent was inserted. Subsequently, he was discharged home and re-admitted for an elective robotic cholecystectomy and bile duct clearance 6 weeks later. Methods Robotic CBD clearance was performed using DaVinciXi system, a 12mm Airseal and four 8mm robotic ports. The patient was supine with split legs(15 degrees), in reverse Trendelenburg position and left tilt. The CBD was dissected out, the anterior duct wall was delineated and longitudinal choledochotomy was carried out. A large stone was extracted through the choledochotomy site followed by removal of stent. Subsequently, a cholangioscopy was performed using a single-use flexible ureteroscope and no further stone disease was identified proximally or distally. Following this, a bile duct closure was performed using 4-0 Polydioxanone interrupted sutures and SutureCut Needle Driver. Results There were no intra- or post-operative complications. The patient made an excellent recovery from robotic common bile duct clearance and was discharged home less than 24 hours post procedure. Conclusions This video presentation highlights the technical aspects of robotic common bile duct clearance and demonstrates that the robotic system allows for accurate dissection and precise suturing which could reduce the risk of bile duct stricture.

Multidetector computed tomography evaluation of obstructive jaundice: a cross-sectional study from a tertiary hospital of Nepal

Background: The utilization of advanced multidetector computed tomography (MDCT) technology along with postprocessing reconstruction techniques has significantly enhanced the clarity of visualization of the hepato-biliary tree. Therefore, this study was conducted to evaluate the diagnostic statistics of MDCT and its associated features in the evaluation of obstructive jaundice, with respect to surgical or histopathological diagnoses. Methods and methodology: The authors conducted a cross-sectional study among 30 participants with obstructive jaundice using purposive sampling. The authors calculated the diagnostic statistics of non-neoplastic and neoplastic types, along with specific etiologies of obstructive jaundice identified through MDCT using a statistical package for social sciences (SPSS) v21 and MedCalc v12.3.0. The ethical clearance was obtained from the institutional review committee of BPKIHS, Nepal (Ref no: Acd/291/075/076-IRC). Results: The sensitivity and the negative predictive value of MDCT for non-neoplastic cause to detect obstructive jaundice were 100% (95% CI: 79.41–100.00) and 100% (95% CI: 75.29–100.00), while the specificity and the positive predictive value for neoplastic cause to detect obstructive jaundice were 100% (95% CI: 79.41–100.00) and 100% (95% CI: 75.29–100.00), respectively. Similarly, the accuracy for either non-neoplastic or neoplastic cause was 96.67% (95% CI: 82.78–99.92). The most common cause of obstructive jaundice was choledocholithiasis (33.34%) followed by cholangiocarcinoma (20%), ampullary carcinoma (13.33%), and choledochal cyst (13.33%). The diagnostic accuracy of the individual etiology of common causes of obstructive jaundice ranged from 82.78 to 100%. Biliary obstruction was most frequently observed in the periampullary region (83.33%), followed by the proximal common bile duct (6.67%), hilar region (6.67%), and intrahepatic region (3.33%). Conclusion: The MDCT could serve as the initial and time-efficient excellent imaging modality for diagnosing various causes of obstructive jaundice with greater accuracy. It can differentiate non-neoplastic from neoplastic causes of obstructive jaundice.

Primary Neuroendocrine Tumor in Type-1C Choledochal Cyst

Cholangiocarcinoma is the most common biliary tumor and a dreaded complication of choledochal cyst. However, the development of neuroendocrine tumor (NET) in choledochal cyst is very rare due to the paucity of Kulchitsky cells. Here, we are presenting a case report on primary NET in choledochal cyst. To date, only four case reports have been published globally and all of them were diagnosed postsurgically; this is the first case diagnosed prior. A 45-year-old female presented with abdominal pain. Imaging showed dilated common hepatic duct and proximal common bile duct with soft-tissue mass lesion in the lateral wall, infiltrating the liver with liver metastasis (suspected as cholangiocarcinoma). As the patient was inoperable, palliative care was planned. To have tissue diagnosis, we proceeded with endoscopic retrograde cholangiopancreatography and brush cytology, but no malignant cells were detected. Image-guided biopsy was done, and surprisingly, the report came to be NET. To rule out occult metastasis elsewhere, positron emission tomography–computed tomography (DOTANOC) scan was done, which was suggestive of a primary bile duct growth with multiple liver metastases. Because of slow growth, nonfunctional nature, and clinical and radiological resemblance with cholangiocarcinoma, biliary tract NETs are very difficult to diagnose preoperatively.

Case Report: Choledocholithiasis as Risk Factor for Klatskin Tumor: A Rare Cholangiocarcinoma

Background: Klatskin tumor is a rare liver cancer that involves the bile ducts. Its incidence begins to increase over time and is usually only diagnosed in patients who are already at an advanced stage. The annual incidence of klatskin tumors is not more than 1:100,000. Klatskin tumor is suspected based on signs of biliary obstruction, ultrasonography showing a stricture or bile mass, cholangiography with ERCP and MRCP, abnormal liver function tests, and elevated tumor marker CA 19-9. Case Report: A 65-year-old man presented to the hospital with complaints of yellowing of the eyes and body that began one month ago, as well as a lump in the right upper abdomen that had grown larger over the previous five months. Physical examination revealed yellow eyes, and a palpable lump in the upper quadrant of the patient's abdomen. The patient defecates looked like putty and urinates looked like tea. The diagnosis leaded to a klatskin tumor because the results of MRCP showed a mass in the hilar region of the liver that extended to the proximal common bile duct, which described the appearance of a klatskin tumor. There were an increasing CA 19-9 level and liver function tests. Conclusion: Patient has been diagnosed with klatskin tumors, has choledocholithiasis risk factor, supported by appropriate MRCP images and increasing CA 19-9 level

Acute lymphoblastic leukemia in an adult presenting with intractable pruritus.A Case report and review of literature.

This case report describes a case of an unusual initial presentation of acute lymphoblastic leukemia in a 22 year male. He presented with intractable pruritus, weight loss and loss of appetite for 1 month in the gastroenterology outpatient department. On investigating, his liver function test was deranged .Magnetic resonance cholangiopancreatography was suggestive of focal narrowing of proximal common bile duct with dilated intrahepatic biliary radicles. A complete serological evaluation for infective and autoimmune profile was negative. Patient underwent image guided liver biopsy. The core of biopsied liver showed infiltration by nests of round to oval tumor cells with markers consistent with B lymphoblastic leukemia /lymphoma not otherwise specified.

Proximal Common Bile Duct Adenomyoma: A case report

Proximal Common Bile Duct Adenomyoma: A case report

S1926 A Young Female With Acute Cholangitis Due to Type IVa Choledochal Cyst With an Undifferentiated Spindle and Giant Cell Carcinoma Hiding Inside

Introduction: This patient is being presented to demonstrate the rarity and severity of extrahepatic biliary cystic masses as the primary etiology of acute cholangitis in a young patient, after failing endoscopic stent placement. Case Description/Methods: A 29-year-old female with no medical history presented with 2 days of sharp, epigastric pain radiating to the back associated with fevers and non-bilious vomiting. Patient’s exam noted scleral icterus and abdominal exam showed tenderness to palpation in the right upper quadrant. Labs showed a WBC of 26,300, AST of 114, ALT of 289, ALP of 343 IU/L, and total bilirubin of 9.76 mg/dL. Computed tomography (CT) of the abdomen showed dilated proximal extrahepatic CBD with a large complex cystic mass in the porta hepatitis measuring 10 cm x 9 cm x 8 cm and this was contiguous with gallbladder and proximal common bile duct with mass effect on duodenum and pancreatic head concerning for Type I choledochal cyst. An ERCP showed a significantly dilated CBD with cystic dilation and balloon sweep with 9-10-12 mm balloon catheter was performed with passage of a small stone and pus. Two plastic stents 10 Fr x 7 cm and 10 Fr x 9 cm were placed with appropriate bile drainage. Fevers continued and total bilirubin increased to 14.2 mg/dL and ALP reached 535 IU/L, therefore patient was taken for laparoscopy which showed large choledochal cyst intimately involved with the head of the pancreas and duodenum, necessitating a Whipple procedure for distal margin. Proximal margin entered the left and the right hepatic ducts, consistent with a type IVa choledochal cyst. Anatomic pathology of the 7.0 cm x 6.0 cm x 3.0 cm mass in the cyst showed an undifferentiated spindle and giant cell carcinoma, confined to the bile duct histologically, with lymphovascular and perineural invasion present. There was no gallbladder involvement and 25 lymph nodes were negative for malignancy. The patient improved and was discharged to home after extended recovery (Figure). Discussion: Undifferentiated carcinoma of the extrahepatic biliary system is extremely rare and has been previously found on middle-age to elderly patients. Diagnosis of undifferentiated carcinoma of the extrahepatic biliary system is difficult because the exact diagnosis cannot be determined prior to surgical resection. Patients with undifferentiated carcinoma of the extrahepatic bile duct may have a relatively better prognosis due to the early appearance of jaundice, compared to those with gallbladder involvement.Figure 1.: MRCP of Type IV choledochal cyst

S1712 Choledochal Cyst Mimicking the Gallbladder With a Surprising Twist

Introduction: Choledochal cysts are congenital rarities and often a pediatric diagnosis but 20% go undetected until adulthood. Etiology remains unclear but an obstructed common bile duct (CBD) has been identified as a pathogenic feature. We present a rare case of choledochal cyst initially mimicking the gallbladder in an elderly female. Case Description/Methods: A 90-year-old woman presented to the hospital for abdominal pain and unintentional weight loss. Past medical history was notable for breast cancer and colorectal cancer status post resection. Liver function tests and pancreatic markers were normal with mildly elevated alkaline phosphatase. CT abdomen and pelvis revealed a 2.8 cm dilated common bile duct (CBD), choledocholithiasis, pancreatic duct dilation and absent gallbladder. Patient however denied undergoing a cholecystectomy. Given the discrepancy of imaging and history, an abdominal ultrasound was performed demonstrating large gallstones in the gallbladder with normal CBD size. Endoscopic ultrasound (EUS) revealed a 28x26 mm mass in the ampulla (Figure). FNB was performed. The distal CBD measured 7 mm with a 35 mm proximal CBD consistent with a choledochal cyst full of large stones. Pancreatic duct measured up to 8 mm. Gallbladder was confirmed to be surgically absent. ERCP was performed which revealed an infiltrative 3-4 cm mass at the major papilla. Pancreatic and biliary sphincterotomies were performed and metal stents were placed in the ventral pancreatic duct and CBD. Biopsies taken revealed pancreatic adenocarcinoma. The following month, hepatobiliary surgery performed a Whipple procedure (pancreaticoduodenectomy). Pathology findings confirmed pancreatic adenocarcinoma with metastasis to one of twelve lymph nodes. Patient was arranged to follow up with outpatient oncology. Discussion: Choledochal cysts can be an elusive diagnosis in elderly adults given its rarity, prevalence in children, and common presentation of vague abdominal pain. Choledochal cyst should be part of the differential diagnosis regardless of patient age especially in cases of accompanying weight loss due to its increased risk of biliary malignancy. In our case, the patient was found to have choledochal cyst misrepresented as the gallbladder and incidentally found to have pancreatic adenocarcinoma. Additionally, patients may be unreliable historians leading to misinterpretation of imaging results. Further investigation is therefore warranted in these perplexing cases for an accurate diagnosis and appropriate management.Figure 1.: A. Ampullary mass B. Pancreatic duct dilation C. Choledochal cyst. D Post ERCP.

A Tertiary Care Center's Experience with Clinicopathological Characteristics of Gallbladder Carcinoma in Our Population.

IntroductionGallbladder cancer (GBC) is the most common malignant biliary tract tumor with the shortest survival from the time of diagnosis. This poor prognosis is due to the destructive biologic behavior of GBC, lack of sensitive screening tests for early detection, and vague nature of first presentation. Here in this study, we will evaluate the baseline characteristics of the patients presenting with gallbladder carcinoma in our population.Materials and methodsThis retrospective study was conducted in the Department of Gastroenterology at Sindh Institute of Urology and Transplantation (SIUT), Karachi. Patient data were compiled and composed from the in-patient health records, radiology, and operational records. Those patients with suspicion of GBC, but negative at histology, or patients having inconclusive radiologic findings, were excluded. Baseline characteristics were recorded. Results were presented as means ± SD for quantitative data or as numbers with percentages for qualitative data. Continuous variables were analyzed using the Student's t-test, while categorical variables were analyzed using the Chi-square test. A p-value of <0.05 was considered statistically significant.ResultsA total of 162 patients were included in our study. Among them, 101 (62.3%) were females. Hypertension was the most common comorbid illness noted in 29 (17.9%) patients while 91 (56.2%) patients had no concurrent comorbidities. Most common risk factor for carcinoma of gallbladder was gallstones seen in 106 (65.1%) patients. The most common presenting complaint was combination of obstructive jaundice, weight loss with right hypochondrial pain seen in 66 (40.7%) patients. On CT abdomen, direct liver infiltration without lymphovascular invasion was noted in 77 (47.5%) patients followed by liver infiltration along with lymphovascular invasion in 26 (16%) patients and distant metastasis in 24 (14.8%) patients. On gallbladder (GB) mass biopsy, 58 (35.8%) patients had well-differentiated, 46 (28.4%) had moderately differentiated, while 33 (20.4%) had poorly differentiated adenocarcinoma. Of 162 patients, 103 (63.6%) patients underwent endoscopic retrograde cholangiopancreatography (ERCP). The most common finding on ERCP was proximal common bile duct (CBD) stricture with intrahepatic biliary system dilatation which was noted in 95 (58.6%) patients. Percutaneous transhepatic cholangiography (PTC) was performed only in 9 (5.6%) patients. Seventeen (10.5%) patients were managed by simple cholecystectomy, 39 (24.1%) patients underwent extended cholecystectomy, 14 (8.6%) patients underwent chemotherapy, while 102 (56.8%) patients were given palliative management. When followed for 1 year, 101 (62.3%) patients died within 6 months.ConclusionThe baseline characteristics, biopsy findings, modes of treatment, and rates of 1 year mortality were studied in patients with gallbladder carcinoma in our population. Advanced age, high white blood cell counts, and serum bilirubin at presentation with low lymphocyte count and presence of comorbid illnesses were the factors independently associated with increased mortality in patients with gallbladder carcinoma. However, further studies with large sample size and stratification with respect to age, gender, and different variables can be done in terms of mortality in patients with gallbladder carcinoma.How to cite this articleAkbar N, Yaseen T, Muhammad A, et al. A Tertiary Care Center's Experience with Clinicopathological Characteristics of Gallbladder Carcinoma in Our Population. Euroasian J Hepato-Gastroenterol 2022;12(1):35–39.

Primary Sclerosing Cholangitis in a Paediatric Patient: An Atypical Presentation

Primary sclerosing cholangitis (PSC) is an autoimmune chronic liver disease that studies have shown is rare in children. Here, a challenging case of PSC in a 13-year-old male, without preceding manifestations of inflammatory bowel disease and with evidence of biliary obstruction, is reported. The patient presented with progressive scleral icterus; their total bilirubin and alkaline phosphatase levels were raised, with negative autoimmune work-up, and an ultrasound scan of their abdomen was unremarkable. Magnetic resonance cholangiopancreatography revealed marked dilatation of the intra- and extrahepatic bile ducts, with strictures in the hepatic duct and proximal common bile duct (CBD). Endoscopic retrograde cholangiopancreatography revealed a very narrow CBD with high-grade severe biliary stricture at the common hepatic duct. A cholangiogram revealed the beaded appearance of the intrahepatic ducts, and a left percutaneous external biliary drainage tube was placed. Overall, the findings were suggestive of PSC with high-grade CBD strictures. This case is unique due to the absence of preceding clinical manifestations of inflammatory bowel disease and predominantly obstructive symptoms at the time of presentation, which is highly unusual in the paediatric population.

An Unusual Case of COVID-19: What Is This 3D Printed Model of the Biliary Tree?

An Unusual Case of COVID-19: What Is This 3D Printed Model of the Biliary Tree?

Successful treatment of an iatrogenic biliary stricture using holmium laser "recanalization" and multistenting technique.

A 55-year-old woman admitted for jaundice 2 months after cholecystectomy underwent magnetic resonance imaging, which showed a common bile duct (CBD) stricture. Cholangiography during endoscopic retrograde cholangiopancreatography ([Fig. 1]) confirmed a tight stricture of the proximal CBD and lack of visualization of the intrahepatic bile ducts (IHBD). At cholangioscopy using SpyGlass DS (Boston Scientific), a complete stricture of the proximal CBD was observed with a metallic clip visible inside the CBD ([Fig. 2]). The on-call interventional radiologist performed a percutaneous transhepatic biliary drainage (PTBD) procedure in order to try a rendezvous approach. Percutaneous contrast medium injection confirmed dilated IHBD with complete absence of the proximal CBD lumen for a length of at least 5 mm. Multiple attempts to pass a guidewire through the stricture, both percutaneously and endoscopically, failed.

IGG4-related Sclerosing Cholangitis Mimicking Cholangiocarcinoma: A Case Report

Introduction: IgG4-related sclerosing cholangitis may have variable clinical presentations and may sometimes mimic cholangiocarcinoma. We present a case of a 42-year-old male with IgG4-related sclerosing cholangitis who was initially diagnosed as cholangiocarcinoma. Case report: A 42-year-old gentleman presented with history of progressive jaundice for one month associated with generalized weakness and loss of appetite. His total and direct bilirubin were 5.7 and 4.8 mg/dl, respectively, with an ALP of 1570 U/L. CECT revealed an ill-defined soft tissue enhancing component infiltrating the lumen of the common hepatic duct, distal cystic duct, and proximal common bile duct. In addition, the MRCP of the patient showed an ill-defined lesion around the gall-bladder neck that was effacing a part of the distal cystic duct and a long segment of common hepatic duct suspicious of cholangiocarcinoma. With a provisional diagnosis of cholangiocarcinoma, the patient was subjected to diagnostic laparoscopy, which revealed scirrhous tissue encasing the proper hepatic artery and portal vein and prominent lymph nodes around the hepatoduodenal ligament. There were no ascites or evidence of peritoneal metastasis. Biopsy of the lesion revealed inflammatory cells comprising of lymphocytes, plasma cells, and eosinophils; there were no atypical or malignant cells. IgG-4 marker was positive and immuno-reactive in 5-6% of plasma cells. The patient’s symptoms were completely relieved after three months of steroid therapy. Conclusion: IgG4 -related sclerosing cholangitis can mimic cholangiocarcinoma. Although the disease is rare and its diagnosis remains challenging, knowledge of the disease is valuable when considering the differential diagnosis of obstructive jaundice.

P-BN30 Retroperitoneal biloma: a case report of spontaneous retroperitoneal bike leak and collection

Abstract Background Retroperitoneal biloma is a rare complication of gallstone disease. Only a handful of cases have been reported in the literature with various mechanisms postulated. Here, we report a case of spontaneous retroperitoneal biloma arising from gallbladder perforation. Methods An 87-year-old female patient presented with right upper quadrant pain in the context of known gallstone disease. Inflammatory markers and liver function tests were deranged. Cross sectional imaging found acute cholecystitis and a gallbadder neck perforation with an impacted 2cm proximal common bile duct (CBD) stone. A cholecystostomy was placed and she improved clinically. However, inflammatory markers remained high, and a subsequent computed tomography (CT) found a large collection in the retroperitoneum. Results The retroperitoneal collection measured 14cm x 7cm, and there had been evidence on prior CT scans of retroperitoneal inflammation. It was urgently drained under ultrasound guidance and found to contain bilious content. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) was unable to retrieve the CBD stone, but left stents either side of the stone. The patient clinically and biochemically improved. She was discharged and had an elective ERCP, which successfully retrieved the stone, with a plan for urgent elective laparoscopic cholecystectomy. Conclusions Here, we report an interesting case of retroperitoneal biloma successfully managed with ultrasound-guided drainage. Perforation of the distal CBD can result in retroperitoneal bile leak, but the proximal CBD stone in this case would have likely prevented passage of bile. A more likely cause is adhesion of the gallbladder neck to the posterior parietal peritoneum due to chronic inflammation, with subsequent perforation and release of bile into the retroperitoneum. This has previously been described in the literature. Regardless of mechanism, knowledge of the potential for this rare complication is important for anticipating and appropriately managing complications of gallbladder perforation.

Single-Breath-Hold MRI-SPACE Cholangiopancreatography with Compressed Sensing versus Conventional Respiratory-Triggered MRI-SPACE Cholangiopancreatography at 3Tesla: Comparison of Image Quality and Diagnostic Confidence.

To compare two magnetic resonance cholangiopancreatography (MRCP) sequences at 3 Tesla (3T): the conventional 3D Respiratory-Triggered SPACE sequence (RT-MRCP) and a prototype 3D Compressed-Sensing Breath-Hold SPACE sequence (CS-BH-MRCP), in terms of qualitative and quantitative image quality and radiologist’s diagnostic confidence for detecting common bile duct (CBD) lithiasis, biliary anastomosis stenosis in liver-transplant recipients, and communication of pancreatic cyst with the main pancreatic duct (MPD). Sixty-eight patients with suspicion of choledocholithiasis or biliary anastomosis stenosis after liver transplant, or branch-duct intraductal papillary mucinous neoplasm of the pancreas (BD-IPMN), were included. The relative CBD to peri-biliary tissues (PBT) contrast ratio (CR) was assessed. Overall image quality, presence of artefacts, background noise suppression and the visualization of 12 separated segments of the pancreatic and bile ducts were evaluated by two observers working independently on a five-point scale. Diagnostic confidence was scored on a 1–3 scale. The CS-BH-MRCP presented significantly better CRs (p < 0.0001), image quality (p = 0.004), background noise suppression (p = 0.011), fewer artefacts (p = 0.004) and better visualization of pancreatic and bile ducts segments with the exception of the proximal CBD (p = 0.054), cystic duct confluence (p = 0.459), the four secondary intrahepatic bile ducts, and central part of the MPD (p = 0.885) for which no significant differences were found. Overall, diagnostic confidence was significantly better with the CS-BH-MRCP sequence for both readers (p = 0.038 and p = 0.038, respectively). This study shows that the CS-BH-MRCP sequence presents overall better image quality and bile and pancreatic ducts visualization compared to the conventional RT-MRCP sequence at 3T.

Breath-hold 3D magnetic resonance cholangiopancreatography at 1.5 T using a deep learning-based noise-reduction approach: Comparison with the conventional respiratory-triggered technique

ObjectivesTo assess the image quality of conventional respiratory-triggered 3-dimentional (3D) magnetic resonance cholangiopancreatography (Resp-MRCP) and breath-hold 3D MRCP (BH-MRCP) with and without denoising procedure using deep learning-based reconstruction (dDLR) at 1.5 T. MethodsForty-two patients underwent MRCP at 1.5 T MRI. The following imaging sequences were performed: Resp-MRCP and BH-MRCP. We applied the dDLR method to the BH-MRCP data (BH-dDLR-MRCP). As a qualitative analysis, two radiologists rated the visibility of the proximal common bile duct (CBD), pancreaticobiliary junction, distal main pancreatic duct, cystic duct, and right and left hepatic ducts. Artifacts and overall image quality were also rated. The signal-to-noise ratios (SNRs), contrast ratios, and contrast-to-noise ratios (CNRs) of the CBD images were calculated for quantitative analysis. ResultsBH-MRCP was successfully performed in a single BH. The qualitative and quantitative measurements for BH-dDLR-MRCP were significantly higher than for BH-MRCP (P < 0.02 and P < 0.001, respectively), and the qualitative measurements for BH-dDLR-MRCP were equivalent to or higher than for Resp-MRCP (P = 0.048–1.000). The SNRs and CNRs for BH-dDLR-MRCP were significantly higher than for Resp-MRCP (P < 0.001 and P = 0.001, respectively). ConclusiondDLR is useful and clinically feasible for BH-MRCP at 1.5 T MRI, and enables rapid imaging without loss of image quality compared to conventional Resp-MRCP.

S1500 A Case of Trematodiases in Rice Farmer With Abdominal Pain

Introduction: Liver flukes can cause parasitic inflammatory disease of the bile ducts. The clinical manifestation depends on the degree of infection and the presence of complications. The vast majority of patients are asymptomatic, although symptoms are typically nonspecific complaints such as abdominal discomfort, nausea, and vomiting. We present a case of intrahepatic biliary obstruction secondary to trematodiases in a patient who complained of vague abdominal discomfort. Case Description/Methods: A 66-year-old Chinese man with a past medical history of hypertension initially presented to his outpatient primary care physician with a chief complaint of abdominal pain for three months associated with bloating. His blood work was consistent with obstructive jaundice. Magnetic resonance cholangiopancreatography (MRCP) revealed a dilated common bile duct (CBD) to 0.9 cm with multiple small filling defects, initially thought to represent calculi. He underwent endoscopic ultrasonography (EUS), which also revealed a small filling defect in the CBD (Figure 1). He subsequently underwent endoscopic retrograde cholangiopancreatography (ERCP). The cholangiogram revealed an irregularly shaped filling defect in the proximal CBD (Figure 2). Multiple balloon sweeps of CBD were performed resulting in extraction of a worm-like organism (Figure 3). Pathology revealed the organism to be a hepatic trematode (Figure 4). Upon further questioning, the patient revealed that he had worked as a rice paddy farmer in rural China until 2016. He often ate cooked snails and did not keep a diet of undercooked or raw freshwater fish. The patient felt well post-procedure and is currently planned for treatment with praziquantel. Discussion: Despite the fact that most patients infected with liver fluke are typically asymptomatic, long standing infection can result in chronic inflammation of the bile ducts, leading to development of suppurative cholangitis and eventually, cholangiocarcinoma, decades after initial infection. Obstructive jaundice in patients with associated risk factors such as living in endemic areas (Southeast Asia), occupation (rice farmer, fishermen), and other high-risk behaviors (raw freshwater fish consumption) should prompt evaluation for parasitic infections. Liver fluke infection is an important medical condition with potentially life-threatening consequences that is commonly mis-/under-diagnosed, therefore clinicians should maintain a high index of suspicion for this disorder in at-risk patients.Figure 1.: EUS image showing filling defect in CBD.Figure 2:: Cholangiogram with irregular filling defect of proximal CBD.Figure 3.: Worm-like organism extracted from CBD.Figure 4.: Histopathology revealing hepatic trematode.

Laparoscopic management of perihilar cholangiocarcinoma

Surgical management of perihilar cholangiocarcinoma remains the only available treatment option with curative intent and potential influence on overall survival. Complete laparoscopic resection of perihilar cholangiocarcinoma with biliary reconstruction is a challenging procedure. A sixty-eight-year-old man was presented with a history of fever and abdominal pain. He had a clinical and biochemical picture of obstructive jaundice with a direct bilirubin of 25 mg/dL and alkaline phosphatase of 422. His Ca 19-9 values were raised. CT scan showed an irregular wall thickening of proximal common bile duct with dilatation of upstream bile ducts (Bismuth type I). A preoperative per-cutaneous transhepatic biliary drainage was done to correct hyperbilirubinaemia. The laparoscopic resection of perihilar cholangiocarcinoma was performed with 5 trocars. The procedure included hepatoduodenal lymphadenectomy, common bile duct resection and hepaticojejunostomy. Intraoperative frozen section was performed to confirm negative resection margins. The operative time was 210 minutes with an estimated blood loss of 150 mL. Final histopathology revealed a perihilar cholangiocarcinoma of size 1.7 × 1.6 × 1.3 cm, moderately differentiated adenocarcinoma invading beyond the wall of the bile duct and nodes free of tumor (0/7), with positive lymphovascular emboli. The patient was discharged on the 9th postoperative day with no complications. The patient was discharged on the 9th postoperative day with no complications. Based on our experience, laparoscopic management of perihilar cholangiocarcinoma can be technically safe and feasible.

Single-use duodenoscope in the management of an elderly patient with difficult bile duct stones: laser lithotripsy using a disposable cholangioscope.

Video 1Single-use duodenoscope in the management of an elderly patient with difficult bile duct stones using laser lithotripsy and a disposable cholangioscope.