Subsequent Endoscopic Retrograde Cholangiopancreatography Research Articles

BN SO12 - Management Strategies for Complications in Common Bile Duct Exploration: A Single Unit Comprehensive Analysis

Abstract Background 10-20% of individuals with systemic gallstones are estimated to have common bile duct stones (CBDS)(1). Laparoscopic common bile duct exploration (LCBDE) and two stage laparoscopic cholecystectomy (LC) with subsequent endoscopic retrograde cholangiopancreatography (ERCP) are clinically equivalent in their purpose but associated with different risks and require different skill sets, training and facilities. This study has retrospectively reviewed all LCBDE in our Benign Upper Gastrointestinal Surgery Unit, in particular analysing complications, the management strategies employed, and the impact associated with these interventions. Method A retrospective analysis was conducted on all patients (n=427) who underwent LCBDE between November 2013 and May 2024 at our benign Upper Gastrointestinal Surgery Department to evaluate complications. Comparison is made with British Benign Upper Gastrointestinal Surgical Society (BBUGSS) standards. Results 16.6% (n=71) experienced complications; 3.28% (n=14) retained stone, 3.74% (n=16) bile leak, 9.6% (n=41) non-specific surgical complications. Bile leak approaches were transcystic (n=2), transcystic converted to cholecdochotomy (n= 3), and choledochotomy n=11. Leaks were diagnosed on ERCP (50%), drains (n=3), CT (n=4) and clinical suspicion (n=1). 50% (n=8) were managed by ERCP, n=6 laparoscopic washout, and n=2 conservatively. Of retained stones, n=5 were indicated intraoperatively, n=7 on readmission with pain, n=1 on tubogram, and n=1 due to increased drain output. 80% (n=12) managed via ERCP with sphincterotomy +/- stenting. Of the remainder n=1 underwent open exploration, and n=1 managed conservatively. Conclusion Bile duct complications can be life altering and thus early identification and management is paramount. BBUGSS’ recommended performance standards for LCBDE state that frequency of retained stones should be <15%, bile leaks <5% and return to theatre <5% (2). In our trust rates are 3.51%, 3.74% and 1.64% respectively. Our stone clearance rate is 96.49%, higher than the BBUGSS standard of >85% (2). Our findings conclude that a benign UGI unit in a District General Hospital can deliver a one stage approach with good management of complications from LCBDE.

HPB SO35 - Outcomes of Transcystic Laparoscopic Common Bile Duct Exploration at the time of Laparoscopic Cholecystectomy in patients with small common bile duct diameter

Abstract Background Laparoscopic Cholecystectomy with Laparoscopic Common Bile Duct Exploration (LC+LCBDE) is a single stage therapeutic option for management of choledocholithiasis. There have been limited publications regarding the feasibility of transcystic LCBDE in patients with small (≤8mm) common bile ducts (CBD). This study seeks to examine the outcomes for patients with small ducts who underwent LC+LCBDE via a transcystic approach (LCBDE-t) in a district general hospital over a thirty-month period. Method Prospectively collected data regarding all patients who underwent LC+LCBDE-t over a period from January 2022 to June 2024 was retrospectively reviewed. Data including indication for surgery, CBD diameter, length of stay, complication rate, and readmission rate were determined from Electronic Care Records. Data were analysed using Microsoft Excel. Results 76 patients were identified. CBD diameter (almost all as measured at pre-operative Magnetic Resonance Cholangiopancreatography [MRCP]) ranged from 3.5mm to 8mm (average 6.32). One patient required conversion to open surgery due to difficulties with the LC element of the operation. Median postoperative length of stay was 1 day (range 0-32 days) and readmission rate was 5.33%. Five patients experienced a complication beyond Clavien-Dindo Grade II, with the most serious two being a bile leak and a postoperative bleed, both of which required further surgery. One patient required subsequent Endoscopic Retrograde Cholangiopancreatography (ERCP) for retained CBD stones. Conclusion LCBDE is a safe and effective management option for patients in the setting of choledocholithiasis with small CBD diameter. Small CBD should not necessarily be a deterrent to consideration of transcystic LCBDE as a therapeutic option in appropriately selected patients.

ThP4.10 - Outcomes of Transcystic Laparoscopic Common Bile Duct Exploration at the time of Laparoscopic Cholecystectomy in patients with small common bile duct diameter

Abstract Aim Laparoscopic Cholecystectomy with Laparoscopic Common Bile Duct Exploration (LC+LCBDE) is a single stage therapeutic option for management of choledocholithiasis. There have been limited publications regarding the feasibility of transcystic LCBDE in patients with small (≤8mm) common bile ducts (CBD). This study seeks to examine the outcomes for patients with small ducts who underwent LC+LCBDE via a transcystic approach in a district general hospital over a two-year period. Methods Prospectively collected data regarding all patients who underwent LC+LCBDE over a period from January 2022 to December 2023 was retrospectively reviewed. Data concerning indication for surgery, CBD diameter, length of stay, complication rate, and readmission rate were determined from Electronic Care Records. Data were analysed using Microsoft Excel. Results 50 patients were identified. CBD diameter (as measured at pre-operative Magnetic Resonance Cholangiopancreatography [MRCP]) ranged from 3.5mm to 8mm (average 6.25mm). One patient required conversion to open surgery due to difficulties with the LC element of the operation. Median postoperative length of stay was 1 day (range 0-8 days) and readmission rate was 6%. One patient experienced a complication beyond Clavien-Dindo Grade 2, this caused by a superficial wound infection requiring washout under general anaesthetic. One patient required subsequent Endoscopic Retrograde Cholangiopancreatography (ERCP) for management of retained CBD stones. Conclusions LC+LCBDE is a safe and effective management option for patients in the setting of choledocholithiasis with small common bile duct diameter. Small CBD should not necessarily be a deterrent to consideration of LCBDE as a therapeutic option in appropriately selected patients.

Long-term clinical outcomes of extracorporeal shockwave lithotripsy and endoscopic retrograde cholangiopancreatography for pancreatic duct stone treatment in patients with chronic pancreatitis.

Extracorporeal shock wave lithotripsy for pancreatic stones (P-ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred therapeutic approaches for painful chronic pancreatitis (CP) with pancreatic stones. This study aimed to report the short- and long-term outcomes following P-ESWL and ERCP in a large cohort with CP. Patients with painful CP and pancreatic stones >5 mm in size, who underwent P-ESWL and subsequent ERCP between March 2011 and June 2018, were included in this retrospective-prospective mixed observational study. The total stone clearance rates were recorded. All patients were followed up until the end of March 2024, with the visual analogue scale (VAS) for pain, pain type, quality-of-life scores and other relevant information recorded. A total of 2071 patients underwent P-ESWL, and 93.1% of them subsequently underwent ERCP during the study period. Patients were followed up for an average of 11.8 years from the onset of CP and 6.7 years from the first P-ESWL procedure. Complete stone clearance was achieved in 73.7% of the patients. At the end of the follow-up period, 70.1% of the patients achieved complete pain remission. Significant pain type conversion and lower VAS scores were observed in the patients after treatment. Quality-of-life scores and body mass indices increased after P-ESWL and ERCP. P-ESWL and ERCP are effective and minimally invasive treatments for pancreatic stones in patients with painful CP. Most patients achieved complete pain relief, and pain-type conversion was common after treatment. (ClinicalTrials.gov: NCT05916547).

Biliary Taeniasis: Case Series and Literature Review.

Biliary taeniasis is uncommon in clinical practice. We report two cases in our hospital. The first patient was diagnosed with acute biliary pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) showed a white, flat, segmented 1-cm-wide tapeworm drilling into the duodenal papilla that was identified as Taenia saginata. After tapeworm removal, bile duct sweeping, and anthelmintic therapy, the patient recovered uneventfully. The second patient was diagnosed with acute cholangitis and multiple stones in the common bile duct and gallbladder. Emergency ERCP showed no tapeworm in the duodenum. During a subsequent ERCP 6 days later, a flat tapeworm, also T. saginata, was identified drilling into the duodenal papilla. We review five patients cases with acute acalculous cholecystitis or cholangitis caused by T. saginata or Taenia solium, and 1 patient with T. saginata drilling into the T-tube. Taeniasis should be taken into consideration when dealing with biliary and pancreatic disease.

Flea-Borne Typhus Presenting with Acalculous Cholecystitis and Severe Anemia

Background. Flea-borne typhus (FBT), an uncommon illness in the United States, typically presents as a high continuous fever with commonly associated symptoms including headache, myalgias, and rashes on the trunk and extremities. Patients infected with FBT may also present with atypical symptoms. As such, the combination of its relatively low incidence in the United States coupled with its variability in associated symptoms poses a diagnostic challenge for clinicians; early empiric treatment with doxycycline is warranted prior to a definitive diagnosis to reduce the risk of damage to vital organs. Case Report. This case describes a 54-year-old male who presented to an emergency room in Houston, Texas, with one week of constant right upper quadrant abdominal pain and fevers up to 40°C. The patient was initially diagnosed with Grade III severe acute cholangitis after abdominal ultrasound revealed gallbladder sludge and wall thickening without ductal dilatation, but a subsequent endoscopic retrograde cholangiopancreatography was unremarkable. Following intermittent fevers and worsening anemia, the patient was started on oral doxycycline for atypical infection, and an infectious disease workup subsequently returned a positive titer for Rickettsia typhi. He experienced rapid symptomatic and clinical improvement, and the patient was discharged home with a final diagnosis of flea-borne typhus. Conclusion. Albeit uncommon, the presentation of this patient’s symptoms and final diagnosis of flea-borne typhus demonstrates the importance of (1) keeping atypical infections such as FBT in the differential diagnosis and (2) beginning empiric treatment to prevent damage to vital organs if suspicion of FBT is high.

Timing of ERCP after extracorporeal shock wave lithotripsy for large main pancreatic duct stones.

Extracorporeal shock wave lithotripsy (ESWL) is performed to fragment large main pancreatic duct (MPD) stones in symptomatic patients. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) is often performed to clear the stone fragments. Edema of surrounding tissue after ESWL theoretically affects the ability to perform ERCP. However, the optimal timing of ERCP after ESWL is not clearly defined. The aim of this study is to determine the efficacy and safety of same-day ERCP after ESWL and to determine if the timing of ERCP after ESWL affects outcomes. This is a retrospective study of consecutive patients from January, 2013 to September, 2019 who received ESWL for MPD stones at our center. Included patients received subsequent same-day ERCP under the same general anesthesia session or later session ERCP (1-30days after ESWL). Demographics, anatomical findings, history, and outcomes were collected. Success was defined as complete or near complete (> 80%) stone fragmentation with clearance. 218 patients were treated with ESWL and subsequent ERCP. 133 (61.0%) received ERCP on the same day immediately after ESWL, while 85 (39.0%) returned for ERCP at a later day (median 3.0days after ESWL). Baseline characteristics demonstrated patients who received same-day ERCP had a higher rate of pain at baseline (94.7% vs 87.1%, p = 0.045). Main outcomes demonstrated an overall successful MPD stone clearance rate of 90.4%, with similar rates between same-day ERCP and later session ERCP (91.7% vs 88.2%, p = 0.394). Additionally, successful cannulation at ERCP, adverse events, and post-procedure admission rates were similar. Delaying ERCP to allow peripancreatic tissue recovery after ESWL does not affect outcomes. Same-day ERCP after ESWL is safe and effective.

Clinical impact of pancreatic steatosis measured by CT on the risk of post-ERCP pancreatitis: a multicenter prospective trial

Pancreatic steatosis (PS) may be a risk factor for acute pancreatitis. Whether it is also a risk factor for post-ERCP pancreatitis (PEP) has not been evaluated. This study aimed to determine the impact of PS on PEP development. This multicenter prospective trial enrolled 786 consecutive patients who underwent contrast-enhanced abdominal CT and subsequent first-time ERCP. PS was evaluated based on pancreatic attenuation on unenhanced CT images. The risk of PS for the development of PEP was evaluated using a logistic regression model. Of 527 patients included in the study, 157 (29.8%) had PS and 370 (70.2%) did not. At 24 hours after ERCP, there was a significant difference in the PEP identified in 22 patients (14.0%) in the PS group and 23 patients (6.2%) in the "no PS" (NPS) group (P= .017). Diabetes and hypertension were more common in the PS group than in the NPS group; no differences in dyslipidemia were found. Patients with PS had a higher risk for the development of PEP than those with NPS (odds ratio, 2.09; 95% confidence interval, 1.08-4.03). No other variables were identified as risk factors for PEP. PS is a significant risk factor for PEP for which preventive measures should be considered. Standardized measurement protocols to assess PS by CT are needed. (Clinical trial registration number: KCT0006068.).

One-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiography bile duct stone extraction is a feasible option in Indonesia within the National Health Insurance System.

Bile duct stones are a widespread condition that can pose a significant risk to life due to the occurrence of complications. In recent years, there has been a growing inclination toward the use of one-stage minimally invasive procedures for the treatment of this condition. However, it is important to note that in developing countries, such as Indonesia, where the National Healthcare Insurance System is established, the implementation of these procedures is still relatively uncommon due to limitations in healthcare facilities. This study presents a case series involving 13 patients who underwent a consecutive initial attempt of one-stage Laparoscopic Cholecystectomy with subsequent Intraoperative Endoscopic Retrograde Cholangiopancreatography (LC-ERCP) for the extraction of bile duct stones. These patients were among the 124 individuals treated for bile duct stones at our hospital for one year (June 2022 to May 2023). All the participants in this study were covered by the National Health Insurance. Among the 124 patients diagnosed with bile duct stones, thirteen (10.5%) were subjected to an initial attempt of one-stage LC-ERCP procedure, which had a success rate of 76.4%. However, three of them experienced difficulties during the cannulation of bile duct, leading to the failure of this approach. The patients included in the study had a mean age of 46.5years, with average serum levels of total bilirubin and direct bilirubin measuring 2.1 and 1.4mg/dL, respectively. The average duration of successful and unsuccessful procedures was 121.5min and 183.3min, respectively. The average length of postoperative hospital stay was 3.5days, and no instances of mortality or complications were recorded during the study. One-stage LC-ERCP procedure offered a promising treatment option for bile duct stones in Indonesia, particularly for patients registered under the National Healthcare Insurance System. This approach could serve as a viable alternative for facilities that lack proficiency in LC-CBDE skills. Furthermore, the ability to perform ERCP in a supine position is crucial in achieving a high success rate. The results of this study showed the need for advancements in Indonesian public healthcare facilities to meet the growing demand for improved treatment modalities.

Outcomes of endoscopic retrograde cholangiopancreatography in patients with situs inversus viscerum.

Situs inversus viscerum (SIV) is a congenital condition defined by left-to-right transposition of all visceral organs. This anatomical variant has caused technical challenges in endoscopic retrograde cholangiopancreatography (ERCP). Data on ERCP in patients with SIV are limited to case reports of unknown clinical and technical success rates. This study aimed to evaluate the clinical and technical success rates of ERCP in patients with SIV. Data from patients with SIV who underwent ERCP were retrospectively reviewed. The data were collected by querying the nationwide Veterans Affairs Health System database for patients diagnosed with SIV who underwent ERCP. Patient demographics and procedural characteristics were collected. Eight patients with SIV who underwent ERCP were included. Choledocholithiasis was the most common indication for ERCP (62.5%). The technical success rate was 63%. Subsequent ERCP with interventional radiology-assisted rendezvous has increased the technical success rate to 100%. Clinical success was achieved in 63% of cases. Among cases of subsequent rendezvous ERCP after conventional ERCP failure, clinical success was achieved in 100%. The clinical and technical success rates of ERCP in patients with SIV were both 63%. In patients with SIV in whom ERCP fails, interventional radiology-assisted rendezvous ERCP can be considered.

Multicenter retrospective cohort of EUS-guided anterograde pancreatic duct access

Background and study aims Pancreatic duct (PD) cannulation may be difficult during conventional endoscopic retrograde cholangiopancreatography (ERCP) due to underlying pathology, anatomical variants or surgically altered anatomy. Pancreatic access in these cases previously necessitated percutaneous or surgical approaches. Endoscopic ultrasound (EUS) allows for an alternative and can be combined with ERCP for rendezvous during the same procedure, or for other salvage options. Patients and methods Patients with attempted EUS access of the PD from tertiary referral centers between 2009 and 2022 were included in the cohort. Demographic data, technical data, procedural outcomes and adverse events were collected. The primary outcome was rendezvous success. Secondary outcomes included rates of successful PD decompression and change in procedural success over time. Results The PD was accessed in 105 of 111 procedures (95 %), with successful subsequent ERCP in 45 of 95 attempts (47 %). Salvage direct PD stenting was performed in 5 of 14 attempts (36 %). Sixteen patients were scheduled for direct PD stenting (without rendezvous) with 100 % success rate. Thus 66 patients (59 %) had successful decompression. Success rates improved from 41 % in the first third of cases to 76 % in the final third. There were 13 complications (12 %), including post-procedure pancreatitis in seven patients (6 %). Conclusions EUS-guided anterograde pancreas access is a feasible salvage method if retrograde access fails. The duct can be cannulated, and drainage can be achieved in the majority of cases. Success rates improve over time. Future research may involve investigation into technical, patient and procedural factors contributing to rendezvous success.

Endobiliary radiofrequency ablation of an intraductal vessel in a patient with surgically altered anatomy.

A 49-year-old man with a history of chronic pancreatitis following Whipple procedure presented with hematemesis and hematochezia. Enteroscopy revealed blood throughout the afferent and efferent limbs, with a clot at the hepaticojejunostomy anastomosis ([Fig. 1]). Two subsequent endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed to remove the blood clots ([Fig. 2]) and place biliary stents to manage the hemobilia. Owing to ongoing bleeding, the patient underwent empiric embolization of the left and right hepatic arteries. Despite these efforts, the patient’s bleeding persisted, with associated hemodynamic instability. After a multidisciplinary discussion, the patient was offered salvage endobiliary radiofrequency ablation (RFA).

Impact of the Timing of Endoscopic Retrograde Cholangiopancreatography for the Treatment of Acute Cholangitis: A Meta-analysis and Systematic Review.

The optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis (AC) has not been unequivocally established. To perform a meta-analysis of the outcomes associated with particular timings of ERCP for AC. A systematic literature search was conducted for studies of ERCP for AC, and then a meta-analysis of the in-hospital mortality (IHM), 30-day mortality, and length of hospital stay (LHS) was performed. Seven non-randomized studies of 88,562 patients were considered appropriate for inclusion. Compared with performing ERCP more than 24 hours after admission, ERCP within 24 hours was associated with lower IHM ( P <0.0004), but no difference in 30-day mortality ( P =0.38) was found between the 2 groups. ERCP performed <48 hours after admission was associated with a lower IHM and 30-day mortality ( P <0.00001 and P =0.03) than ERCP performed >48 hours after admission. In addition, ERCP performed within 24 or 48 hours was associated with a shorter LHS ( P <0.00001 and P <0.00001, respectively). ERCP within 48 hours of admission is superior to subsequent ERCP with respect to IHM, 30-day mortality, and LHS, and ERCP performed within 24 hours is associated with lower IHM and LHS.

S111 Outcomes of Endoscopic Retrograde Cholangiopancreatography in Patients With Situs Inversus Viscerum

Introduction: Situs inversus (SIV) is a rare congenital condition defined by the left to right transposition of all viscera as a mirror image. This uncommon anatomic variant has been reported to cause technical challenges while performing endoscopic retrograde cholangiopancreatography (ERCP). Data of patients with situs inversus undergoing ERCP is limited to case reports and the clinical and technical success rate of ERCP in these patients is unknown. The goal of our study is to evaluate the clinical and technical success rates and procedural characteristics of patients with situs inversus undergoing ERCP. Methods: A retrospective review of data from consecutive patients with SIV undergoing ERCP. Data was collected by querying the nationwide Veterans Affairs Health System database for patients with a diagnosis of situs inversus (ICD Q89.3) who underwent ERCP between January 1, 2010, to March 31, 2022. Patient demographic and procedure characteristics were collected (Table). Results: A total of 654 patients with situs inversus were identified. Eight of these patients had undergone ERCP. The median age was age of 68. The most common indication for ERCP was choledocholithiasis (5 patients, 62.5%). The technical success rate (defined as ability to achieve successful biliary cannulation) was 63%. Subsequent ERCP with interventional radiology assisted rendezvous increased the technical success rate to 88%. Clinical success (defined as successful management of choledocholithiasis, cholangitis, stricture, or obtaining specimens for the diagnosis of malignancy) was achieved in 63% of cases. When considering subsequent rendezvous ERCP if conventional ERCP failed, clinical success was achieved in 88% of cases. Conclusion: In our limited series, the clinical and technical success rate of ERCP for patients with SIV is higher than previously reported. In patients with SIV where conventional ERCP biliary cannulation fails, IR assisted rendezvous ERCP can be considered. Table 1. - Patient demographic and procedure characteristics Gender Race Age Indication Technical Success Clinical Success Reason for failure Rendezvous ERCP attempted Rendezvous ERCP technically successful Rendezvous ERCP clinically successful Male White 72 Choledocholithiasis Yes Yes Male African American 74 Pancreatic adenocarcinoma Yes Yes Male White 88 Choledocholithiasis with cholangitis No No Unable to cannulate the ampulla Yes Yes Yes Male White 62 Periampullary Adenocarcinoma Yes Yes Male White 59 Choledocholithiasis No No Unable to cannulate the ampulla No Male White 88 Choledocholithiasis Yes Yes Female Native American 63 Benign biliary stricture Yes Yes Male Hispanic 63 Choledocholithiasis with cholangitis No No Unable to visualize the ampulla Yes Yes Yes

S1888 A Curious Case of Recurrent Pancreatitis: A Case Report

Introduction: Annular pancreas, a congenital anomaly characterized by incomplete rotation of the ventral pancreatic bud, causes a ring of pancreatic tissue to encircle the duodenum. It is commonly accompanied by pancreatic divisum, which occurs when the main pancreatic duct and accessory duct fail to fuse. Patients often present with recurrent pancreatitis due to partial obstruction of the pancreatic duct caused by fibrosis. Case Description/Methods: A 72-year-old Caucasian male presented with recurrent episodes of acute pancreatitis. A CT abdomen (Figure A) revealed pancreatic tissue surrounding the second portion of the duodenum consistent with an annular pancreas. A pancreatic duct stone was also noted. An MRCP (Magnetic resonance cholangiopancreatography) was consistent with annular pancreas with persistent dilation of the main and accessory pancreatic ducts and a 6mm stone noted in the pancreatic duct (Figure B). On an initial ERCP (Endoscopic retrograde cholangiopancreatography), the pancreatic duct could not be cannulated through the major papilla and minor papilla could not be identified due to inflammation. An EUS (Endoscopic ultrasound) was performed, which was suggestive of pancreas divisum. The minor papilla was cannulated, and a stent was placed in the pancreatic duct. In a subsequent ERCP (Figure C), the patient had the pancreatic stone removed, with complete resolution of his symptoms. Discussion: Typically, patients with annular pancreas present with symptoms during childhood. While infrequent, some patients remain asymptomatic until 20-50 years of age. This case demonstrates the potential to remain asymptomatic until even 72 years of age. Thus, it is important for physicians to be aware of the clinical manifestations of annular pancreas, as they could arise at any stage in life. By increasing awareness surrounding annular pancreas and management of its complications, we hope to increase the rate of early intervention.Figure 1.: Image 1A. Contrast-enhanced axial CT of the abdomen at the level of the pancreatic head. The pancreas (white bracket) is seen surrounding the 2nd part of the duodenum (white asterisk), compatible with annular pancreas. A 6 mm calcification (circled) is present in the region of the minor papilla (arrows indicating pancreatic ducts). Image 1B. Coronal MRCP images. Annular pancreas, with only a thin rim of pancreatic tissue surrounding the duodenum. The dorsal duct is best shown to wrap completely around the duodenum on MRCP images (arrow). Image 1C. ERCP fluoro image showing the previously placed pancreatic duct stent (which does appear to have a loop-like configuration) and the pancreatic stone.

S1923 Abutting Percutaneous Drains Can Jeopardize Healing of Post-Cholecystectomy Bile Leaks

S1923 Abutting Percutaneous Drains Can Jeopardize Healing of Post-Cholecystectomy Bile Leaks

S1840 The Importance of Cholangioscopic Biopsies: An IgG4-Related Sclerosing Cholangitis Story

Introduction: IgG4 related sclerosing cholangitis (IgG4-SC) has generally been associated with autoimmune pancreatitis, retroperitoneal fibrosis, and sialadenitis. However, there are rare cases involving only the biliary tree. In addition, IgG4-SC can be easily confused with cholangiocarcinoma and primary sclerosing cholangitis (PSC). IgG4 serum levels more than 135 suggest IgG4-SC, but lower levels do not rule out the disease. Here, we present an atypical case of IgG4-SC. Case Description/Methods: 68-year-old male with past medical history of alcohol misuse disorder presented for pruritis, scleral icterus, and 40 pounds of weight loss in three weeks. On admission, notable labs were AST 158, ALT 81, ALP 713, total bilirubin 5.8, and direct bilirubin 4.9. IgG was 3203 and IgG4 was 113. Remainder of the work up was negative. Magnetic resonance cholangiopancreatography showed isolated left intrahepatic biliary dilation. Endoscopic retrograde cholangiopancreatography (ERCP) showed segmental strictures at the common hepatic duct and left intrahepatic duct. Cholangioscopy showed a fibrotic intraluminal growth in the upper third of the common bile duct, which was unable to be traversed. Biliary brushings showed only acute inflammation (Figure). A plastic biliary stent was placed for decompression and a percutaneous internal-external biliary drain was performed to facilitate subsequent rendez-vous ERCP. Repeat cholangioscopy showed scarring and fibrosis of the entire biliary tree and segmental stricturing at the hilum and left intrahepatic duct. Cholangioscopy-guided forceps biopsies showed more than ten IgG4 cells per high powered field indicating IgG4-SC. Patient was started on high dose corticosteroids with improvement of his symptoms and lab abnormalities. Discussion: Awareness of IgG4-SC is important as it can mimic cholangiocarcinoma and PSC. Our patient presented with obstructive jaundice and isolated dilatation of the biliary tree with a normal serum IgG4 suggestive of underlying malignancy. However, he also had elevation of total serum IgG, which was suspicious for an underlying autoimmune disorder. Biliary brushings can exclude malignancy but have a poor sensitivity for the diagnosis of IgG4-SC (36%). The most useful modality of diagnosis is cholangioscopy-guided forceps biopsy as this is positive in about 88% of specimens. Thus, IgG4-SC should be considered in patients with an atypical presentation of obstructive jaundice with incongruent lab and imaging findings, as this condition is treatable.Figure 1.: Left picture shows common hepatic duct stricturing and mass on cholangioscopy. Right picture shows left intrahepatic duct stone in light of stricturing on cholangioscopy.

Giant Hepatic Subcapsular Hematoma after Endoscopic Retrograde Cholangiopancreatography (ERCP): A Case Report

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most commonly performed minimally invasive procedures for the diagnosis and treatment of biliary and pancreatic diseases. Hepatic hematoma secondary to ERCP is a rare and potentially serious complication with few cases described in the literature. Objective: The objective is to present a case of a giant hepatic subcapsular hematoma (HSH) secondary to ERCP, surgically resolved by laparotomy due to its recurrence and significant growth. Case report: We present the case of a 55-year-old female patient with a history of laparoscopic cholecystectomy and subsequent ERCP due to residual choledocholithiasis. The patient presented intense abdominal pain and fever after being discharged home, so she was admitted to the general surgery service where a HSH was diagnosed. Initially, conservative treatment with imaging follow-up is indicated, however, due to growth of the hematoma and recurrence, surgical treatment is indicated. Conclusion: Most patients respond to conservative treatment, however there will be patients who require surgical treatment, so suspecting this pathology will help provide timely treatment.

The Utility of Abdominal Ultrasound Following Negative Computed Tomography in Diagnosing Acute Pancreatitis.

AimAcute pancreatitis is a diagnosis established by fulfillment of at least two out of three clinical features, including epigastric pain, elevated lipase, and/or radiographic evidence of acute pancreatitis. Computed tomography of the abdomen and pelvis (CTAP) is the gold standard imaging modality for evaluating acute pancreatitis. Although abdominal ultrasound (AUS) is increasingly utilized given the widespread availability and high sensitivity and specificity for detecting gallstone-related complications, including gallstone pancreatitis, the leading cause of acute pancreatitis in the US. However, recent literature has concluded that performing AUS following a negative CTAP rarely led to changes in management and imparted an increased length of service (LOS) in the ED. Our study investigated whether a similar relationship was observed when managing acute pancreatitis in the inpatient setting. We aimed to quantify how performing AUS influenced inpatient LOS for patients admitted for acute pancreatitis without radiographic evidence of acute pancreatitis on CTAP. We also aimed to quantify how AUS influenced the likelihood of subsequent intervention via endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy, including the relative impact of certain demographic or clinical features.MethodsA retrospective analysis was performed using a cohort of 6069 patient encounters extracted via the HCA Healthcare enterprise data warehouse (EDW) database. Inclusion criteria were all adult patients with an index admission for acute pancreatitis between January 1 and December 31, 2019, who underwent CTAP during admission. Patients younger than 18 years, with prior cholecystectomy, or without documentation of demographic or clinical data of interest were excluded. The primary outcome was to quantify how performing AUS within 48 hours impacted LOS for patients admitted for acute pancreatitis following negative CTAP. Secondary outcomes examined whether AUS changed management (i.e., per likelihood of subsequent ERCP or cholecystectomy). This included determining the influence of various demographic or clinical characteristics on the likelihood of intervention via ERCP or cholecystectomy. Linear regression was used to determine the effect of performing AUS on the duration of LOS. Logistic regression was used for covariate analysis based on demographic (BMI, sex, race, age) and clinical data (comorbid conditions, abnormal labs, and vital signs).ResultsPatients with acute pancreatitis who underwent AUS within 48 hours had a reduced LOS of 1.099 days. Patients who underwent AUS were 1.126 times more likely to undergo subsequent ERCP than those who received CTAP alone. Patients who received AUS following CTAP were also 2.711 times more likely to undergo subsequent cholecystectomy. Increasing age and BMI were correlated with an increased likelihood of ERCP and cholecystectomy. Males were less likely to undergo cholecystectomy (OR = 0.753) and ERCP (OR = 0.815) compared to females.ConclusionPerforming AUS within 48 hours following negative CTAP in this cohort of patients admitted for acute pancreatitis was associated with a decreased LOS. Furthermore, patients who underwent AUS were more likely to undergo ERCP and even more likely to undergo cholecystectomy. The likelihood of ERCP and cholecystectomy increased proportionally to both age and BMI. Females were more likely than males to undergo subsequent ERCP or cholecystectomy.

Critical Illness Cholangiopathy in COVID-19 Long-haulers

Critical Illness Cholangiopathy in COVID-19 Long-haulers