Common Bile Duct Stricture Research Articles

Subtotal Cholecystectomy in Preventing Major Complications in Difficult Cholecystectomy Cases: A Comprehensive Single Center Study

ABSTRACT Background: Cholecystectomy is a commonly performed laparoscopic surgery but because of variability in anatomy, surrounding inflammation and fibrosis because of recurrent attacks of cholecystitis, can be a potentially difficult surgery. Laparoscopic total cholecystectomy in difficult gall bladder cases sometimes can cause severe complications. Laparoscopic subtotal cholecystectomy can be a bridge and a safe and feasible option between open subtotal cholecystectomy and laparoscopic cholecystectomy. Aim: To study indications, morbidity and clinical outcomes in patients undergoing subtotal cholecystectomy with laparoscopy or with open surgery. Settings and Design: It was a prospective observational study. Patients presenting with signs and symptoms of cholecystitis in either OPD or IPD and in emergency were included in this study. Materials and Methods: Total 38 patients who presented to our institute with clinical and ultrasonographic evidence of acute cholecystitis were included in the study. All patients underwent detailed and thorough clinical examination, laboratory investigations, ultrasonographic, and contrast enhanced computed tomography scan in selected patients. Based on intraoperative findings, decision of subtotal cholecystectomy either by laparoscopy or via open method was made. Various outcomes like intraoperative complications, postoperative complications and need of postoperative interventions, hospital stay, and returning to daily activity were observed and charted. Statistical Analysis: The data obtained were tabulated in Microsoft Excel and analyzed using SPSS version 17.0. Continuous variables were expressed as mean ± standard deviation value. Probability value (P value) was used to determine the level of significance. P value <.05 was considered as significant; P value <0.001 was considered as highly significant. Results: The common indications for subtotal cholecystectomy were severe cholecystitis with dense fibrous adhesions (97.4%), empyema (34.2%) or gangrenous gallbladder (31.6%), and Mirizzi syndrome (2.6%). Conversion rate was 21.1%. Morbidity rates were relatively low with subtotal cholecystectomy (bile leak 21.1%, sub hepatic collections 10.5%, retained stones 5.3%, paralytic ileus 18.4%, wound infection 7.9%, and common bile duct stricture 2.6%). Postoperative interventions were necessary in 18.4% of the cases (retained stones 5.3%, bile leak 7.9%, common bile duct stricture 2.6%, and subhepatic collection 2.6%). Mean duration of hospital stay was 7.5 days and returning to routine daily activity was 11.05 days. Conclusion: Subtotal cholecystectomy is a safe and feasible method for difficult gallbladder cases with a positive outcome. Laparoscopic subtotal cholecystectomy decreases the conversion rate in difficult gallbladder cases but it is not a substitute to open conversion if deemed necessary.

Hiatal Hernia with Prolapse of the Pancreas Causing Bile Duct Stricture and Liver Function Disorders: A Case Report and Literature Review.

Hiatal hernia is a common condition in elderly patients, but the additional presence of prolapse of the pancreas is extremely rare. We herein report an 89-year-old woman who presented with liver function disorders and abdominal pain. Her laboratory tests revealed cholestasis, and imaging examinations showed stenosis of the common bile duct pulled toward the hernia sac. She was diagnosed with a common bile duct stricture due to pancreatic herniation and underwent laparoscopic surgery. Our review of the literature identified three types of pancreatic herniations: asymptomatic, bile duct complication, and acute pancreatitis. Pancreatic head herniation tends to induce bile duct complications.

Fully Covered Metal Stents Safely Facilitate Extraction of Difficult Bile Duct Stones.

Ten to 15% of the common bile duct (CBD) stones require advanced endoscopic extraction techniques during endoscopic retrograde cholangiopancreatography. The study aimed to evaluate the efficacy and safety of fully covered self-expandable metal stents (FC-SEMS) for facilitating the extraction of difficult bile duct stones. Patients who received FC-SEMS for the extraction of difficult CBD stones were retrospectively reviewed. Group 1 included patients with extrahepatic stones above a distal CBD stricture, Group 2 included patients with intrahepatic stones above a hilar stricture, and Group 3 included patients with complex stone(s) and no biliary stricture. Complete stone clearance rate and complications of FC-SEMS treatment were evaluated. The study group included 33 procedures on 32 patients (mean age: 55±17, 56.3% male). FC-SEMS was placed as a primary treatment in 15 (45.5%) procedures. Complete stone clearance was achieved in 84.6% of the procedures in Group 1, 100% in Group 2, and 87.5% in Group 3 (P=0.23). Overall, complete stone clearance was achieved in 30 of the 33 procedures (90.9%). None of the patients developed pancreatitis, cholecystitis, or cholangitis. Stent migration occurred in 4 procedures (12.1%), and all were clinically insignificant. FC-SEMS is effective and safe for facilitating treatment of difficult bile duct stones.

Frequency of common bile duct strictures in patients presenting with obstructive jaundice in Ayub teaching hospital

Background; Obstructive jaundice in simple terms means the outflow of bile has been obstructed anywhere from the liver to the duodenum. It is caused by obstruction, blockage and/or compression of common bile duct (CBD) and/or biliary tract that leads to incomplete excretion of bile into the intestine. Patients with obstructive jaundice usually present with Complains of abdominal pain, yellow discoloration of skin and/or eyes, pale stools, dark colored urine, nausea, vomiting and pruritus. Objective: To determine frequency of common bile duct strictures in patients presenting with obstructive jaundice in Ayub teaching hospital. Material and Method. This Cross Sectional Study was conducted in the department of Gastroenterology, ATH, Abbottabad from 15th September 2020 to 15th March 2021. A total of 135 patients of both gender presenting with jaundice and having serum bilirubin ≥1.1 mg/dl, alkaline phosphatase ≥140 IU/L along with evidence of obstruction of common bile duct were included in the study. Presence of CBD stricture was confirmed through Ultrasonography or CT abdomen. Results: Age range in this study was from 20 to 80 years with mean age of 44.651±12.90 years. Female gender was dominant with 61.5% patients. Common bile duct strictures was seen in 9.6% patients.

Pediatric Autoimmune Pancreatitis: A Single-Center Retrospective Case Series.

Autoimmune pancreatitis (AIP) is a rare form of a chronic, immune-mediated, inflammatory pancreatic condition. There is limited data regarding presentation and outcome in the pediatric population. We described a single-center case series of 4 pediatric patients with AIP to better understand the presentation, symptoms, and outcomes of this rare condition. Data collected included demographics, serology markers, symptoms at presentation, imaging, additional organ involvement, histology, treatment methods, and outcomes. The diagnosis of AIP was made by a combination of serology, pancreatic imaging, histology, extrapancreatic manifestations, and steroid response. All patients were diagnosed with type 2 AIP. Abdominal pain, emesis, and obstructive jaundice were the most common symptoms at presentation. Autoimmune markers were negative. Cross-sectional abdominal imaging showed diffuse/focal pancreatic gland enlargement and common bile duct stricture universally and main pancreatic duct irregularity in half of the patients. Biopsies showed lymphoplasmacytic infiltration with associated pancreatic fibrosis and atrophy. Treatment with an 8-week tapering course of prednisone showed prompt response with resolution of symptoms and normalization of laboratory test results. Our case series shows that AIP in children is a rare entity with a distinct clinical presentation, classical radiographic and histological features with good long-term prognosis.

Management of common bile duct injuries and strictures: maintaining optimal blood supply in the anastomosis

Management of common bile duct injuries and strictures: maintaining optimal blood supply in the anastomosis

3D-modelling and 3D-printing in diagnosis and treatment of common bile duct stricture

An example of the use of 3D-modeling of 3D-printing in the diagnosis and choice of a surgical approach for the treatment of hepaticocholedochal stricture is given. The inclusion of meglumine sodium succinate (intravenous drip, once a day, 500 ml, course of 10 days) into the therapy regimen was substantiated, which contributed to the reduction of intoxication syndrome due to its antihypoxic mechanism of action and, as a result, to a reduction in the duration of hospitalization and an increase in the quality of life of the patient.

Safety and Feasibility of Primary Closure Following Laparoscopic Common Bile Duct Exploration for Treatment of Choledocholithiasis

BackgroundT-tube drainage following laparoscopic common bile duct (CBD) exploration may lead to T-tube displacement and water–electrolyte disorders, affecting patients’ quality of life. In particular, biliary peritonitis may develop in a small number of patients after T-tube removal, requiring reoperation. This prospective cohort study was performed to investigate the safety and feasibility of primary closure following laparoscopic CBD exploration for the treatment of choledocholithiasis.MethodsPatients who were treated for choledocholithiasis by laparoscopic CBD exploration with primary closure from January 2019 to March 2022 comprised the PC group (n = 145). Patients who were treated for choledocholithiasis by laparoscopic CBD exploration with T-tube drainage during this period comprised the TD group (n = 153). Perioperative and follow-up outcomes were collected and statistically analyzed.ResultsThe TD and PC groups showed significant differences in the operation time (124.6 ± 40.8 vs. 106 ± 36.4 min, P = 0.000) and postoperative hospital stay (7.1 ± 2.6 vs. 5.9 ± 2.0 days, P = 0.000). No significant difference was observed in terms of blood loss, the ratio of conversion to laparotomy, and postoperative parameters. Preoperative albumin and total bilirubin levels were the risk factors of bile leakage after surgery. No patients developed CBD stricture or carcinogenesis, The rates of residual and recurrent stones in the TD and PC groups were 1.97% vs. 1.40% and 1.31% vs. 1.40%, respectively, with no significant difference (P = 1.000 for both).ConclusionsPrimary closure following laparoscopic CBD exploration is safe and feasible for selected patients with choledocholithiasis.

HPB P33 Management of Gallstone Disease with Deranged Liver Function Tests – Single Centre Experience

Abstract Background Laparoscopic cholecystectomy (LC) has emerged as the gold standard for the treatment of symptomatic cholelithiasis, however, things are not quite so clear when it comes to managing cholelithiasis with suspected common bile duct (CBD) stones and debate continues among surgeons about the optimal pathway of management. The current recommendation is that patients with symptomatic cholelithiasis should be investigated for CBD stones. There is controversy because investigating for suspected choledocholithiasis by means of Magnetic resonance cholangiopancreatography (MRCP)/ pre-operative or post-operative Endoscopic retrograde cholangiopancreatography (ERCP)/ laparoscopic cholecystectomy with on-table cholangiography (OTC) may lead to subsequent over or under treatment with significant morbidity, readmissions, decline in Health Related Quality of Life (HRQoL) and costs to the health service. We conducted a retrospective clinical audit to compare our care provision for symptomatic gall stone disease with suspected choledocholithiasis against the guidelines laid down by Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) in 2016, NICE (2014) and European Society of Gastrointestinal Endoscopy (ESGE). This also highlights the importance of a single stage approach (LC with OTC) for management of gall stones with suspected CBD stones. Methods A retrospective audit was conducted for 18 months at a referral centre for hepato-pancreato-biliary (HPB) diseases, with available expertise for management of CBD stones, endoscopically and surgically. All patients admitted to general surgery facility with a diagnosis of gallstone disease with deranged liver function tests (LFTs), and suspicious of having or diagnosed to have common bile duct stones were included in the study. Patients aged 18 years and above with symptomatic gall stones suspected to have or diagnosed with choledocholithiasis were included, while patients with cholelithiasis but no evidence of stones in CBD on initial investigations were excluded. A total of 95 patients who met the inclusion and exclusion criteria were included in the study. We used the guidelines put forth by AUGIS (2016), NICE guidelines (2014), British Society of Gastroenterology (BSG) in 2017 and European Society of Gastrointestinal Endoscopy (ESGE) 2019 to compare management of symptomatic gallstone disease. Data with regards to length of hospital stay, comorbidities, investigations done, diagnosis, management, readmissions before undergoing further investigations or having a surgery (laparoscopic cholecystectomy) with or without on-table cholangiogram (OTC) were analysed. Data analysis for this set of data was done using numbers, percentages and descriptive statistics, using SPSS 25.0. Results Out of 95 patients, 90 had deranged LFTs at presentation (3 presented with cholangitis) and 5 had suspicious findings on initial imaging. The diagnosis included Mirizzi syndrome, pancreatitis, Choledocholithiasis, Biliary colic, Acute cholecystitis and benign CBD stricture. Out of 95 patients, 76 of them had Ultrasound abdomen as their initial investigation, mostly on the day of admission. 41 patients had MRCP, 73% of them during their index admission. Amongst the 95, 59% underwent ERCP, 76.8% of them during the index admission. The median time from admission to MRCP and ERCP was 5 and 8 days, respectively. Out of 56 patients who underwent ERCP, 9 of them had it done within 72 hours of admission. Overall, 22 patients underwent LC with OTC. Out of 95 patients, 51 patients underwent LC. Out of 79 patients who were fit for surgery, 28 of them were still awaiting surgery. Amongst 18 patients who had Pancreatitis at presentation, 14 of them underwent ERCP. Out of which 3 of them had LC during index admission. The maximum length of stay observed amongst 95 patients was 36. Amongst the 95 patients, the study also records that 13 patients had readmissions before they underwent ERCP or LC. Conclusions We found 16% compliance with the guidelines in regards to the timing of biliary decompression with ERCP. Our results show 66.66% compliance with guidelines, with regards to timing of biliary decompression in Cholangitis. The study reflects a significant non-adherence to the guidelines as 68.40% of patients could not have definitive management within the recommended time frame. Looking into the finer details, we found that 35.40% of the patients did not have their surgery at the time of the audit. 22% of patients had LC performed in accordance with the recommendations, while the timing of surgery in 78% of patients showed no compliance with the guidelines. Guidelines for management of patients with gallstone disease associated with CBD stones was not met for majority of patients. A significant number of patients were readmitted to the hospital because of delay in receiving further investigations or definitive surgery. There may be a role for multidisciplinary team meetings to identify patients requiring expedited ERCP, which in turn may translate into early definitive surgical management. Laparoscopic cholecystectomy with OTC, with or without laparoscopic CBD exploration or post-operative ERCP can be incorporated as an alternative to pre-operative ERCP to reduce patient morbidity and length of hospital stay.

Benign biliary strictures associated with acute biliary pancreatitis.

There are limited data about the benign biliary strictures (BBS) which can develop during the clinical course of acute biliary pancreatitis (ABP) due to compression of the common bile duct (CBD) by edematous and inflamed pancreatic tissue. We aimed to determine the incidence of BBS due to ABP and its clinical course after endoscopic management. The study was retrospectively conducted among patients with ABP who were admitted to a single tertiary reference center during 3years. BBS-ABP was defined as distal narrowing of the CBD with proximal dilatation and delayed drainage of the contrast into the duodenum. Endoscopic treatment was performed by inserting a single 7F or 10F plastic stent which was exchanged every 3months until stricture resolution. Patients were followed for 1year after stricture resolution. Seven hundred and twenty-one patients had ABP during the study period. Among them, 257 (35.6%) patients underwent ERCP and 26 patients (3.6%) had CBD stricture due to ABP. A 7 Fr plastic stent was inserted in 18 patients and 10 Fr in 8 patients. The stricture was completely resolved at 3months in 66.7%, at 6months 23.8% and at 9months (9.5%) of the patients. There was no procedure-related complications other than asymptomatic stent migration in 4 (19%) patients. None of the patients had recurrent biliary stricture during the 1year stent-free follow-up period. BBS-ABP is a frequently seen clinical entity. In most patients, the stricture improves within 3months and temporary endoscopic stenting prevents the patients from the consequences of the obstruction during this period.

A Comparative Study of Endoscopic Ultrasound Fine-Needle Aspiration (EUS-FNA) and Endoscopic Retrograde Cholangiopancreatography (ERCP)-Based Brush Cytology for Tissue Diagnosis in Malignant Biliary Obstruction.

Background and objective Patients with suspected malignant biliary strictures frequently undergo endoscopic retrograde cholangiopancreatography (ERCP)-based brush cytology and endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for establishing the diagnosis. The outcomes of these tests aid in the further management of the patient. A comparison of these two modalities in establishing the diagnosis is seldom reported. In light of this, we aimed tocompare the diagnostic efficacy between ERCP-based brush cytology and EUS-FNA for tissue diagnosis in malignant biliary obstruction. Our study involved a retrospective audit of all patients admitted to the Vydehi Institute of Medical Sciences and Research Centre for EUS and ERCP from 2015 to 2019. Methodology A Comparative study was conducted in the Department of Medical Gastroenterology at the VydehiInstitute of Medical Sciences and Research Centre over a five-year period. A total of 77 subjects who presentedduring the study period with biliary obstruction based on clinical presentation with altered liver function test in an obstructive pattern and evidence of biliary obstruction in the form of stricture or pancreaticobiliary mass on cross-sectional imaging were included in the study. All the patients included in the study underwent EUS and ERCP. Results The majority of the patientsin the study were in the fifth decade of life with a slight female predominance. The most common CT finding was a periampullary mass with common bile duct (CBD) stricture (59.7%). In the study, EUS-FNA was more sensitive than ERCP-based tissue sampling. The overall sensitivity was 90.63% for EUS-FNA and 65.63% for ERCP sampling. EUS-FNA was found to have diagnostic accuracy of 92.63% in comparison to 71.43% for brush cytology. Conclusions Based on our findings, EUS-FNA is superior to ERCP-based tissue sampling with excellent sensitivity and diagnostic accuracy. Performing EUS before ERCP in allpatients with suspected malignant biliary obstruction would definitely improve diagnostic accuracy and thereby help in the management of such cases.

Hepatobiliary and Pancreatic: An unusual cause of biliary obstruction.

A 41-year-old man, with no relevant personal history, presented with postprandial fullness, nausea, and weight loss in the last 2 years. On physical examination, he had mild jaundice. Laboratory examination revealed conjugated hyperbilirubinemia (total bilirubin 3.62 mg/dL, conjugated bilirubin 2.60 mg/dL) and cytocholestasis with cholestatic predominance (AST 102 U/L, ALT 144 U/L, FA 330 U/L, GGT 681 U/L). An abdominal computed tomography followed by magnetic resonance cholangiopancreatography (MRCP) showed common bile duct (CBD) stenosis, without mural thickening or intraluminal mass, and intrahepatic and extrahepatic duct dilation. There were no lesions in the hepatic or pancreatic parenchyma (Fig. 1). Endoscopic retrograde cholangiopancreatography (ERCP) showed a heterogeneous filling defect in the distal half of the CBD with upstream dilatation. Biliary sphincterotomy and exploration with a balloon were performed, and tumor tissue fragments with a villous appearance and necrotic areas were obtained. Cholangioscopy allowed the identification of a friable villous vegetative lesion in the middle third of the CBD leading to luminal narrowing (Fig. 2). Biopsies revealed an intraductal tubulopapillary neoplasm with high-grade dysplasia and focal transformation into adenocarcinoma (ADC). Staging exams excluded lymph node or distant metastasis, and, after multidisciplinary discussion, the patient underwent Whipple's cephalic pancreatoduodenectomy with hepaticojejunostomy. The anatomopathological examination of the surgical specimen showed a moderately differentiated ADC in intestinal-type intraductal papillary neoplasm of the bile duct (IPNB) (pT1N0R0) (Fig. 2). There was no indication for adjuvant chemotherapy, but clinical, analytical, and imaging surveillance was recommended. After 1 year of follow-up, the patient remains asymptomatic. IPNBs are rare neoplasms arising from the bile duct considered to be an important precursor of cholangiocarcinoma. They are commonly found in Far East Asia where hepatolithiasis and clonorchiasis are endemic. IPNBs can occur anywhere in the extrahepatic or intrahepatic bile ducts and microscopically are classified into four types: pancreaticobiliary, intestinal, gastric, and oncocytic. Most cases show at time of diagnosis high-grade intraepithelial neoplasia or invasive carcinoma. IPNBs secrete mucin and induce biliary obstruction and dilation, but do not have a typical clinical or imaging presentation, making their early diagnosis a clinical challenge. The major treatment is surgical resection with a better prognosis compared to cholangiocarcinoma.

S2858 Post-ERCP Subcapsular Hepatic Hematoma

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is both a diagnostic and therapeutic procedure used for management of biliary pathology. Rates of even the most common complications, including biliary perforation and pancreatitis, are low, however other complications can be life-threatening and must be kept in mind when evaluating a patient post-ERCP. Here, we describe a case of post-ERCP subcapsular hepatic hematoma (SHH). Case Description/Methods: A 39-year-old man with a history of hypertension, type II diabetes mellitus and alcohol use disorder complicated by chronic pancreatitis with multiple episodes of common bile duct (CBD) stricture status post multiple ERCPs presents with epigastric pain and right upper quadrant pain. He was admitted two weeks prior for epigastric pain, where he was found to have CBD stricture, and underwent ERCP with stent placement. Pain did not completely resolve after his last hospitalization and escalated to a 10/10. On arrival, he was afebrile with stable vitals. Physical exam demonstrated epigastric tenderness to palpation with voluntary guarding, but a soft abdomen without rebound tenderness. Labs significant for WBC count of 10.8 x 10^9/L, alkaline phosphatase of 117 U/L, and hemoglobin 11.7 g/dL. Abdominal ultrasound showed a 7.3 x 3.9 cm area of mixed echogenicity in the right liver lobe. Triple phase CT of the abdomen and pelvis showed a 9 x 6.5 x 2.5 cm heterogeneous subcapsular liver collection. He was given Zosyn, and WBCs downtrended. On day 3, liver function tests (LFTs) rose: aspartate aminotransferase was 397 U/L, alanine aminotransferase was 206 U/L, alkaline phosphatase was 571 U/L, and total bilirubin was 5.0 mg/dL. Repeat CT showed expected hematoma resolution with correct biliary stent placement. Antibiotics were re-started. LFTs and symptoms improved. He was discharged on a 14-day course of Levofloxacin and Metronidazole. (Figure) Discussion: SHH is a rare but known complication of ERCP. Hematomas can expand, resulting in significant anemia and LFT elevation, or become infected with resultant sepsis. Patients with SHH must be carefully monitored in the post-ERCP setting. This patient exhibited an elevated WBC count with delayed elevation in LFTs, concerning for potential infection of the hematoma, yet without overt signs of infection, including lack of fever. He was managed with antibiotics without hematoma drainage, demonstrating the efficacy of conservative management for such a potentially deadly complication of ERCP.Figure 1.: Triple phase computed tomography scan of the abdomen and pelvis demonstrating a right-sided subcapsular hematoma in segment 6 of the liver in the coronal (a) and transverse (b) planes (arrow).

S1724 Eosinophilic Cholangitis: A Great Mimic

Introduction: Eosinophilic Cholangitis (EC) is a rare infiltrative disorder of the biliary tree and a diagnostic dilemma. The initial presentation mimics malignancy and is distinguished by histopathology. Steroid response supports the diagnosis. This case elucidates the diagnostic and therapeutic approach to EC in a patient with acute jaundice. Case Description/Methods: A 44-year-old female with a history of SLE and marginal cell lymphoma in remission presented with fevers, leukocytosis, abdominal pain, and hyperbilirubinemia. She underwent an ERCP that showed a common bile duct (CBD) stricture with stent placement that was removed 6 weeks later (Figure). She then underwent a cholecystectomy for chronic cholecystitis with an intraoperative liver biopsy for persistently elevated LFTs (AST 512 U/L, ALT 500 U/L). Surgical specimens showed dense eosinophils at the cystic duct margin with mild non-specific lobular inflammation involving 15% of liver parenchyma. Six months later, she presented to our hospital with worsening abdominal pain and jaundice. Pertinent labs included a total bilirubin of 16.9 mg/dL, AST 321 U/L, ALT 335 U/L, and alkaline phosphatase 2700 U/L. MRCP showed CBD narrowing at the hilum with intrahepatic ductal dilation She underwent an ERCP which identified a Bismuth IV hilar stricture and a ductal polypoid mass on cholangioscopy. Two biliary stents were placed across the stricture into the right and left intrahepatic ducts. A direct biopsy, while negative for malignancy, revealed marked eosinophilia. Labs included peripheral eosinophilia of 0.78 x109/L. IgG4 and Anti-mitochondrial antibody were normal. A month later, repeat ERCP with stents exchange and ductal mass re-biopsy was performed given high concern for malignancy, however again demonstrated sheets of eosinophils. After multidisciplinary discussion, she was presumptively diagnosed with EC and started on 40mg of prednisone. Seven weeks later, repeat ERCP showed complete resolution of the stricture. LFTs and bilirubin normalized. Her symptoms resolved and she was transitioned to azathioprine for maintenance. Discussion: EC is a rare, benign process affecting the biliary system and poses a significant diagnostic challenge. Our case supports proposed diagnostic criteria for EC, including biliary stricture, eosinophilic infiltration on histopathology, and steroid responsiveness. Our case is unique in our demonstration of the direct cholangioscopy view of this benign entity and the utility of cholangioscopy in achieving the diagnosis.Figure 1.: a) Ductal polypoid mass near common hepatic duct identified via endoscopic retrograde cholangiopancreatography with cholangioscopy. b) Intrahepatic biliary ductal dilatation seen on magnetic resonance cholangiopancreatography. c) Occlusion cholangiogram during endoscopic retrograde cholangiopancreatography showing a Bismuth Type IV common bile duct stricture. d) Occlusion cholangiogram during endoscopic retrograde cholangiopancreatography showing resolution of the common bile duct stricture after steroid treatment. e) Biliary stricture biopsies showing fragments of bile duct mucosa with acute and chronic inflammation with marked eosinophilia. f) Ductal mass/biliary stricture biopsy demonstrating inflammation and eosinophilia on Hematoxylin-eosin stain.

S1886 A Case Report of Iatrogenic Common Bile Duct Stricture

Introduction: Iatrogenic bile duct injuries (IBDIs) are common postsurgical complications following cholecystectomy. IBDI vary from a minor bile leakage to biliary stricture or a complete occlusion of the common bile duct. The authors report a case of a common bile duct stricture caused by suture material after an open cholecystectomy. Case Description/Methods: A 57-year-old male with history of NAFLD presented with acute onset of severe epigastric abdominal pain, nausea and vomiting. Lipase was elevated. CT scan of the abdomen/pelvis revealed gallbladder wall thickening and dilated extrahepatic bile ducts consistent with cholecystitis and biliary obstruction. The patient underwent an open partial fenestrated cholecystectomy which was complicated by injury of the gastric antrum requiring primary two-layered repair and omental patching. ERCP was not performed due to gastric injury. His symptoms improved and he was discharged home. One month later he returned with severe epigastric pain. Initial work-up revealed elevated lipase and transaminases. CT of the abdomen/pelvis showed peripancreatic fluid and fat stranding with persistent mild biliary dilatation. MRCP identified three choledocholiths at the level of the ampulla. ERCP was performed with sphincterotomy, balloon extraction of several stones and sludge, and placement of a plastic biliary stent. There was an area of resistance felt during balloon sweep. He was discharged after symptom resolution with recommendations to repeat ERCP in 6 weeks for stent removal. A repeat ERCP revealed persistent area of resistance with filling defect on fluoroscopy. (Figure). A spyglass revealed a suture material and mild inflammation in the CBD at the cystic duct takeoff (Figure). Stone formation induced by suture material is thought to be the culprit of the recurrent acute pancreatitis. Discussion: IBDIs account for the majority of postsurgical complications after cholecystectomy. The incidence of IBDIs is higher in laparoscopic cholecystectomy when compared to open cholecystectomy. IBDIs are associated with significant perioperative morbidity, mortality, and prolonged hospital stay. If left untreated, they can result in life-threatening complications such as cholangitis, secondary biliary cirrhosis, and portal hypertension. One of the uncommon postoperative complications is stone formation induced by suture material used in cystic duct ligature. Surgical sutures can function as a nidus for crystallization leading to obstruction and development of large choledocholiths.Figure 1.: Top. ERCP shows filling defect in the common bile duct. Bottom: Spyglass shows suture material and adjacent mild imflammation of the CBD at the systic duct takeoff.

S2996 Erdheim-Chester Disease Associated With Aggressive Sclerosing Cholangitis

Introduction: Erdheim-Chester disease (ECD) is a rare histiocytosis recently recognized as a neoplasm due to discovery of MAPK pathway mutations. ECD can involve multiple systems, but hepatic involvement is exceedingly rare. Case Description/Methods: A 64-year-old male presented with fatigue, pruritis, 15-pound weight loss, bilirubin 1.8 mg/dL (0.3-1), and alkaline phosphatase (ALP) 1671 IU/L (44-147). MRCP showed multifocal, short segment dilation of intrahepatic ducts only. Liver biopsy showed periportal and focal bridging fibrosis suggesting primary sclerosing cholangitis (PSC). Anti-smooth muscle, anti-mitochondrial, antineutrophil cytoplasmic antibodies (ANCA) were negative, IgG subclasses normal. A month later he developed emesis, weakness, and leukocytosis. CT scan showed perinephric and periaortic soft tissue stranding suggestive of ECD. 18FDG PET/CT showed a 2.1x2.9 cm highly FDG avid mediastinal mass, follicular lymphoma on biopsy. He improved with antibiotics but returned after a few days with emesis, leukocytosis, and bilirubin 10.7 mg/dL, ALP 1277 IU/L. CT scan showed progressive perinephric and periaortic soft-tissue encasement (Figure1A). Endoscopic retrograde cholangiopancreatography showed a common bile duct (CBD) stricture and non-filling right hepatic duct. Despite CBD stenting bilirubin continued to rise. He now had molluscum like skin lesions which on biopsy revealed dermal proliferation of CD68+, Factor XIIIa+, CD1a- histiocytes and multiple giant cells characteristic of ECD (Figure1B). Targeted therapy with BRAF or MEK pathway inhibitors was considered though there was concern that he may be too sick to receive these. Patient and family opted for comfort care. Discussion: Despite symptoms, cholestatic liver function and biopsy suggestive of PSC, several factors make us question this diagnosis; such as lack of inflammatory bowel disease or positive ANCA which are seen in 60-80% patients with PSC. PSC is usually indolent, time from diagnosis to death or liver transplant generally being 10-12 years. This patient was transitioned to hospice within 6 months. This makes us suspect hepatic involvement with ECD or an overlap syndrome, or that PSC associated with ECD runs a much more aggressive course. Though liver and CBD biopsies did not show ECD, it is not unusual for biopsy findings in ECD to be obscured by non-specific fibrosis. We want to highlight that a negative biopsy should not delay diagnosis of ECD if imaging is indicative, especially as effective therapy is now available.Figure 1.: 1A: CT abdomen showing perinephric soft tissue stranding and encasement. B: extensive histiocytic infiltration (majority of cells) seen on skin biopsy.

S1891 A Diagnostic Dilemma: Primary Sclerosing Cholangitis With High IgG4 vs IgG4-Related Sclerosing Cholangitis

Introduction: Two etiologies of sclerosing cholangitis with overlapping features are Type 2 IgG4-Related Sclerosing Cholangitis (IgG4-SC) and Primary Sclerosing Cholangitis with high IgG4 (PSC). Here, we present a complex case of a young patient with features of both diseases. Case Description/Methods: A 25-year-old Caucasian female with a medical history of diabetes and no previous pancreatic disease was incidentally found to have an AST and ALT in the low 200s, total bilirubin 2.6, and alkaline phosphatase of 1130 concerning for cholestatic obstruction. She was asymptomatic and not jaundiced at the time. Subsequent MRCP revealed a dilated common bile duct. The patient underwent ERCP/EUS demonstrating a common bile duct stricture. A plastic stent was placed, and cells for cytology/FISH analysis were unyielding for malignancy. Repeat ERCP/EUS was performed a few months later for stent exchange. Biopsies to evaluate the indeterminate stricture yielded IgG4+ plasma cells up to 14/HPF. Based on the findings suspicious for IgG4-SC, she started prednisone therapy for one month. Subsequent labs demonstrated mild improvement in alkaline phosphatase to 450, total bilirubin 0.2, and a normal IgG4 level but with persistent elevation of total IgG 1.5 times the upper limit of normal. Repeat ERCP demonstrated resolution of the distal biliary stricture. She never developed abdominal pain, jaundice, weight changes or loss of appetite. Six months later, LFTs began to uptrend and a third ERCP/EUS demonstrated new distal biliary stricture. Biliary biopsies showed dense lymphoplasmacytic infiltrates and fibrosis with an average of 10 IgG4 positive plasma cells/HPF. Liver biopsies showed periductal fibrosis and a fibro-obliterative duct lesion. Given the concern for PSC, colonoscopy was performed with biopsies showing mild crypt distortion, mild eosinophilia, and rare neutrophils in the lamina propria. The patient remained asymptomatic throughout the disease course but had persistent biochemical hepatitis despite being on steroid therapy. A shared provider-patient decision was made to withhold immunosuppressive or biologic therapy. Discussion: In this case, the patient’s epidemiologic, clinical, and histological factors were more consistent with PSC. Conversely, the mild biochemical and stricture steroid-responsiveness were initially more suggestive of IgG4-SC. It is imperative to delineate between the two, as prognosis, treatment-responsiveness, and anticipated comorbidities differ.

S2870 Successful Use of EUS-Guided Choledochoduodenostomy With LAMS in a Post-Liver Transplant Patient With Recurrent Choledocholithiasis and Cholangitis

Introduction: Biliary complications, like anastomotic stricture and cholangitis, are seen in 10-15% of orthotopic liver transplants (OLT). OLTs often require multiple endoscopic retrograde cholangiopancreatoscopy (ERCP) for recurrent disease. Endoscopic ultrasound guided choledochoduodenostomy (EUS-CD) has been effective in treatment of malignant distal biliary obstruction after failed ERCP; however, there are limited reports regarding EUS-CD in OLTs. We present a case of successful EUS-CD with lumen apposing metal stents (LAMS) in an OLT with recurrent cholangitis secondary to benign anastomotic stricture refractory to management with ERCP. Case Description/Methods: A 61-year old female with 3 OLTs (1996 and twice in 2008) for autoimmune hepatitis presented with recurrent cholangitis secondary to anastomotic biliary stricture in the setting of duct mismatch with a dilated common hepatic bile duct to 3 cm. She had recurrent choledocholithiasis measuring 3 cm despite prior mechanical and electrohydraulic lithotripsy with cholangioscopy confirmed clearance. As a result, she had undergone a total of 26 prior ERCP treatments (2012-2021). She underwent an EUS-CD with LAMS for definitive treatment. 2-weeks later, an upper endoscope was traversed through the LAMS to perform lithotripsy of remaining choledocholithiasis. At this time, the patient remains free of cholangitis for the past 8 months. (Figure) Discussion: Biliary complications, like anastomotic stricture and recurrent cholangitis, are a common occurrence in OLTs. With use of various ERCP techniques, obstructions can be removed or ameliorated. Timely treatment of cholangitis is imperative as the mortality rate is high (10-30%). With each cholangitis episode and subsequent ERCP, the cumulative procedural risk and mortality increases. EUS-CD has been demonstrated to be effective in treatment for malignant distal biliary obstruction after failed ERCP. Our patient had previously undergone 26 ERCPs and additionally was on Warfarin for pulmonary embolism putting her at very high risk for complications with additional future endoscopic procedures. This represents a case of successful use of EUS-CD with LAMS in a patient post-OLT with a significant distal common bile duct stricture which had been refractory to traditional management via ERCP. Long term studies are indicated to see if this can provide durable benefit.Figure 1.: 1A. MRI imaging demonstrating a large 3 cm choledocholithiasis within the dilated CBD, which formed as a result of bile stasis. 1B. CT coronal view demonstrating successful deployment of LAMS to complete EUS-CD. 1C. Fluoroscopic view of the standard upper scope traversing through the LAMS for definitive lithotripsy and dredging of remaining choledocholithiasis. 1D. Endoscopic view of the final LAMS placement with double pigtail plastic stents.

P35 Lupus masquerading as Cholangiocarcinoma: One of the many faces of multifaceted lupus

Introduction/BackgroundSystemic lupus erythematosus (SLE) is a complex autoimmune condition which can present with a wide variety of clinical features. This variation can lead to delayed diagnosis or misdiagnosis. Gastroenetrological pathology in SLE is rare but primary autoimmune hepatitis, pancreatitis, lupus enteritis, cholestatic biliary disease and protein losing enteropathy have all been reported. We would like to share the first known presentation of SLE as cholangiocarcinoma.Description/MethodA 62-year-old, previously fit and well, gentleman presented with a 1 month history of painless jaundice, a palpable gallbladder (Courvoisier syndrome), dark urine, pale stool, generalised rash, pruritus, weight loss and anorexia. The presence of these red flag features raised concerns. Initial investigation with Endoscopic retrograde cholangiopancreatography (ERCP) revealed distal common bile duct (CBD) stricture which was further explored with computerised tomography of thorax, abdomen, pelvis and magnetic retrograde cholangiopancreatogram (MRCP) both raising the suspicion of a cholangiocarcinoma in the presence of constitutional symptoms. Several biopsies and brushings taken during multiple ERCP’s failed to identify clear mitotic cells, IgG 4 staining remained negative. Further investigation with Positron emission tomography – computerised tomography (PET-CT) showed significant FDG uptake around the upper part of the stent with final working diagnosis of Cholangiocarcinoma and a Whipple’s procedure was planned.In the interim, the patient developed swollen painful hands, scleritis and a yellow blistering rash. He was referred urgently onto the Rheumatology team after receiving the positive immunology results: ANA (1:1280), Anti double stranded DNA and Rheumatoid Factor (RF) along with hypocomplementemia (C3&C4).Discussion/ResultsSubsequent work up under rheumatology was done considering the possibilities of diagnosis of Systemic lupus erythematosus (SLE), Lupus related autoimmune hepatitis and reactive arthritis as a result of underlying malignancy. Patient’s immunology and other clinical features such as skin rash were strongly supportive of SLE as a primary diagnosis. He was initially treated with low dose prednisolone with dramatic improvement in arthritis and gradual improvement in liver function test. Following MDT discussions with the hepato-biliary team it was felt that lupus was the cause of the biliary stricture which settled well with steroid treatment. A final ERCP was arranged to remove the stent and take final brushings. Methotrexate was started at this point. His SLE remains well controlled on methotrexate and his liver function tests, including bilirubin, remain within the normal range. Patient has now been completely asymptomatic and is discharged from the care of hepatobiliary team with long term follow up for his SLE with rheumatology.Key learning points/ConclusionThis is extremely rare first presentation of SLE presenting with painless jaundice and biliary stricture which improved both biochemically and clinically with treatment of SLE. The key learning points included:Urgent review by rheumatology can facilitate timely diagnosis and preventable admissions/interventions such as major intraabdominal procedure in the form of whipple’s disease planned in our case.Cancer remains a major cause of mortality and morbidity in rheumatological conditions like SLE. Hence initial diagnosis can become extremely difficult if an overlap between these two happens.Treatment options can be limited initially and steroids remain the main stay of treatment till mitotic lesions have been ruled out and disease modifying agents can be used without any contraindications. But disease control for our conditions remains challenging in presence of cancers.

Role of "HinCh Score" as a Non-invasive Predictor of Post-endoscopic Retrograde Cholangiopancreatography Cholangitis.

IntroductionPost-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis (PEC) is associated with increased morbidity and mortality in patients ERCP. The aim of the present study was to analyze the predictors of PEC and to formulate a predictive model for early diagnosis and management.Materials and methodsIt was a cross-sectional study that was carried out at the Sindh Institute of Urology and Transplantation from September 2019 to June 2021. All patients aged between 18 and 75 years and undergoing ERCP due to obstructive jaundice were included. Patients with altered biliary anatomy, history of hepatobiliary surgery, and concurrent sepsis were excluded. Endoscopic retrograde cholangiopancreatography intervention was performed by an expert gastroenterologist. Laboratory parameters (total leukocyte count, total bilirubin, alanine transaminase) and patient temperature were checked on admission, at 12 hours, 24 hours, and 36 hours after ERCP to document PEC.ResultsA total of 349 patients were included in the study. Among them, 176 (50.4%) patients were males. Common bile duct (CBD) stricture was the most common indication of ERCP seen in 148 (42.4%) patients followed by CBD stone and cholangiocarcinoma in 108 (30.9%) and 48 (13.8%) patients, respectively. The most common presenting complaint was jaundice noted in 300 (86%) patients followed by right hypochondrial pain in 280 (80.2%) and weight loss in 194 (55.6%) patients, respectively. Post-ERCP cholangitis developed in 251 (71.9%) patients. On univariate analysis, age >50 years, female gender, right hypochondrial pain, fever, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, TLC of >10,000 cells/L at 12 hours, 24 hours, and 36 hours post-ERCP and rise in ALT >50 IU 24 and 48 hours post-ERCP were significantly associated with PEC. While on multivariate analysis, female gender, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, post-ERCP fever, and rise in TLC of >10000 cells/L at 24 hours post-ERCP were independently associated with PEC. HinCh score was formulated and was found to be significantly associated with the presence of cholangitis. Area under the receiver operating characteristics (AUROC) of HinCh score was 0.74 and at cutoff of ≥4, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HinCh were 81.67%, 59.18%, 83.67%, and 55.71%, respectively with a diagnostic accuracy of 75.36%.ConclusionThe performance of HinCh score in predicting PEC was accurate in 86% of the patients. However, further studies are needed to validate the score.How to cite this articleIsmail H, Yaseen RT, Danish M, et al. Role of “HinCh Score” as a Non-invasive Predictor of Post-endoscopic Retrograde Cholangiopancreatography Cholangitis. Euroasian J Hepato-Gastroenterol 2022;12(1):19–23.