Symptomatic Choledocholithiasis Research Articles

First use of a scoring balloon to perform Oddi sphincteroplasty for biliary stones.

Balloon sphincteroplasty is a well-known procedure for the treatment of biliary stones. Scoring balloons are characterized by rigid tangential elements that provide focal force, achieving a greater pressure than normal balloons. We report the first (to our knowledge) use of a scoring balloon to perform sphincteroplasty in 4 cases of elderly people presenting with symptomatic choledocholithiasis. In all cases we achieved complete common bile duct clearing with good symptom relief. No procedural complications were observed.

Early Onset Cholelithiasis and Macrocytic Anemia: A Fragile Combination

Hemolytic anemia is caused by shortened lifespan of circulating red blood cells (RBCs) due to their premature destruction. Studies have shown that at least 25% of patients with hereditary hemolytic anemia have biliary disease. Early splenectomy is expected to decrease the incidence of gallbladder disease due to decreased activity of the hemolytic process. We present a case report of a patient with early onset symptomatic choledocholithiasis due to undiagnosed hereditary spherocytosis. A 14-year-old female with ADHD presented with two days of progressive right upper quadrant abdominal pain and jaundice. Significant laboratory data included a transaminitis and total bilirubin of 7.7. Right upper quadrant ultrasound revealed gallstones, dilation of the common bile duct (CBD) to 1.3cm, and questionable stone in the distal CBD. Endoscopic retrograde cholangiopancreatography (ERCP) revealed diffuse dilation of the main, right hepatic, and left hepatic bile ducts with largest diameter of 10mm. The lower third of the main bile duct contained one 5mm stone which was removed with biliary sphincterotomy and balloon extraction. Because of jaundice and mild inflammatory distal narrowing, one biliary stent was placed into the CBD. Two days later, the patient underwent cholecystectomy for cholelithiasis and chronic cholecystitis. Elevated reticulocyte distribution width and count, a mean corpuscular volume of 111, and spherocytes on peripheral smear suggested hemolytic disease. Ultimately, the osmotic fragility test returned positive, confirming the diagnosis of early onset cholelithiasis due to hereditary spherocytosis. Though not well established, ERCP is recommended for pediatric patients with symptomatic choledocholithiasis. Hemolytic anemia should be considered in any young person who develops cholelithiasis. When gallbladder disease is noted at time of splenectomy, patients undergo concurrent cholecystectomy, but there is no proven role for prophylactic cholecystectomy. Retrospective studies in adults with hereditary spherocytosis suggest detectable gallstones in 37-43% of patients. Because of the increased incidence of cholelithiasis in hereditary spherocytosis, radiographic gallbladder evaluation is indicated in each patient.2146_A Figure 1 No Caption available.2146_B Figure 2 No Caption available.

Sa1308 ENDOSCOPIC TREATMENT OF SYMPTOMATIC COMMON BILE DUCT STONES IN THE ELDERLY

Regardless of age, in Japan it is recommended that the complete removal of stones be achieved for the management of common bile duct (CBD) stones. However, in many elderly patients stones cannot be safely removed at the initial procedure because of their age and the time required to deal with many and/or large stones. In those patients endoscopic biliary stenting (EBS) is recommended as an alternative. To examine the outcome of endoscopic treatment for elderly patients with symptomatic CBD stones. From January 2016 to May 2017, we performed endoscopic retrograde cholangiopancreatography for 59 elderly patients with cholangitis due to CBD stones. Two groups were evaluated: complete clearance of CBD stones (stone clearance group) and a stenting group where drainage with a 7 Fr. double-pigtail side hole plastic stent was performed. Because of advanced age, there was no plan for regular stent changing. We compared patient profiles, procedure time, adverse events, recurrence rates of cholangitis and the time until recurrence between the two groups. The stone clearance group had 45 patients (26 men) vs. 14 in the stenting group (2 men) (P <0.001). Stenting group patients were significantly older (median age 88, range 78-96) than the stone clearance group (median age 75, range 29-96), P<0.001. The median procedure time was less with stenting than stone removal: 14 min (range 9-26) vs. 27 min (range 6-53), P <0.001. No adverse events occurred in either group. Recurrence of cholangitis was lowest in the stone clearance group [18% (8/45) vs. the stenting group, 43% (6/14), P=0.054]. However, the median time to recurrence of cholangitis was similar between those undergoing stone clearance and stenting [13.8 months (range 1-31) vs. 11 months (range 2-29), P=0.69] (Fig. 1). Although biliary stenting is an effective alternative for acute management of symptomatic choledocholithiasis in ill elderly patients, almost half suffered recurrence of cholangitis. Long term placement of a single stent is not an optimal solution. Whether stone removal after cholangitis subsides or placement of multiple stents would reduce recurrent cholangitis remains to be studied.

Management of endoscopic biliary stenting for choledocholithiasis: Evaluation of stent-exchange intervals.

AIMTo evaluate the best management of plastic stents in patients with choledocholithiasis who were unfit for endoscopic stone removal or surgery.METHODSBetween April 2007 and September 2017, 87 patients (median age 83.7 years) with symptomatic choledocholithiasis were treated with insertion of 7-Fr plastic stents because complete endoscopic stone retrieval was difficult, and their general condition was not suitable for surgery. Seventy of these patients agreed to regular stent management and stent exchange was carried out at every 6 mo (Group A, n = 35) or every 12 mo (Group B, n = 35). The remaining 17 patients did not accept regular stent exchange, and stents were replaced when clinical symptoms appeared (Group C). We evaluated the frequency of biliary complication and stent patency rate during follow-up periods.RESULTSThe patency rate of biliary plastic stents was 91.4% at 6 mo (Group A) and 88.6% at 12 mo (Group B), respectively. Acute cholangitis occurred in 2.9% of Group A patients and in 8.6% of Group B patients. In Group C, median stent patency was 16.3 mo, and stent exchange was carried out in 70.6% of cases because of acute cholangitis or obstructive jaundice. Although a high incidence of acute cholangitis occurred, there was no biliary-related mortality.CONCLUSIONPlastic stent exchange at 12-mo intervals is considered a safe procedure for patients with choledocholithiasis. Long-term biliary stenting increases biliary complications, but it can be an acceptable option for select patients who are medically unfit for further invasive procedures.

Prevalence and Risk Factors for Choledocholithiasis After Cholecystectomy

Introduction: Clinical manifestations of choledocholithiasis include biliary colic, obstructive jaundice, pancreatitis, and acute cholangitis. Prior studies have suggested that presentations of these conditions within 3 years of cholecystectomy (CCY) are more likely due to residual stones missed at time of surgery as opposed to formation of recurrent stones. Complications of retained common bile duct (CBD) stones are well recognized, however there is limited data on pattern and time of presentation. The aim of this study was to determine the pattern of presentation in patients with and without prior CCY. Methods: A retrospective chart review was conducted of patients with biliary pancreatitis, acute cholangitis, or symptomatic choledocholithiasis at a secondary and tertiary care center over a two-year period. The electronic medical record was reviewed to collect the following data: age, sex, race, body mass index, history of CCY and perioperative bile duct evaluation, presence of CBD stone or sludge, and endoscopic retrograde cholangiopancreatography (ERCP) results including maximum CBD diameter and presence of periampullary duodenal diverticulum. Results: 358 patients with biliary pancreatitis, acute cholangitis, or biliary colic due to choledocholithiasis were assessed (Table 1). 100 (27.9%) patients were post-CCY prior to presentation. Demographic and clinical data were reviewed (Table 2). Patients with or without a CCY presented with: 32 (12.4%) vs 6 (6.0%) for biliary pancreatitis (P= 0.078), 33 (12.8%) vs 32 (32.0%) for acute cholangitis (P< 0.001), and 196 (76.0%) vs 62 (62.0%) for symptomatic choledocholithiasis (P=0.008), respectively. Post-CCY patients with a known procedure date had a median recurrence of choledocholithiasis of 210 days with 24 (80%) requiring an ERCP within 3 years.Table: Table. Comparison of Presentation of Choledocholithiasis Between Patients with and Without a CCYTable: Table. Demographic and Clinical DataConclusion: Recurrent biliary obstruction due to post-CCY choledocholithiasis is not uncommon. The disproportionate prevalence of acute cholangitis in post-CCY patients is multifactorial. Given the frequency of gallstone-related disease recurrence within 3 years after CCY, the role of pre-CCY cholangiography should be re-evaluated in future studies. Specifically, the identification of risk factors that predispose patients to recurrent disease would assist in standardization of perioperative CBD evaluation, with a goal of preventing further episodes.

Temporary EUS-Guided Hepaticogastrostomy With Electrohydraulic Shockwave Lithotripsy for Management of Altered Anatomy Choledocholithiasis: 2017 Presidential Poster Award

ERCP is challenging in patients with gastric bypass due to altered anatomy. We report a case of symptomatic choledocholithiasis requiring temporary placement of EUS-guided hepaticogastrostomy with a fully covered metal stent and electrohydraulic lithotripsy. This is a 71-year-old female with a history of multiple abdominal surgeries, including Roux-en-Y gastric bypass with Fobi pouch, appendectomy, cholecystectomy, and adhesiolysis who presented with 4 months right upper quadrant abdominal pain and a 1 week hx of jaundice. MRCP revealed intra and extrahepatic ductal dilatation with a 1.1cm obstructing stone in a tortuous CBD. A double balloon enteroscopy assisted ERCP was considered but initial endoscopy revealed a stricture at the GJ anastomosis thought to be related to complications from the fobi pouch. Given the complex anatomy, surgery was consulted to coordinate a laparoscopic-assisted ERCP. However, due to her extensive surgical history and multiple repeated open abdominal surgeries, they strongly advocated for a non-surgical approach. Interventional radiology was then consulted for a percutaneous approach, but explained that they would require multiple procedures for percutaneous tract dilation before the point that stone extraction could be attempted. As a result, an EUS guided approach was performed via creation of a hepaticogastrostomy. The procedure was performed by puncturing a dilated radical of the left intrahepatic system with a 19G FNA needle. A 0.035mm guidewire was passed antegrade down into the tortuous bile duct. A 6mm balloon catheter was passed into the bile duct and used to dilate the tract. A 10mmx8cm fully covered metal biliary stent was placed from the gastric pouch to the intrahepatic ducts with confirmation made with cholangiogram. A pediatric gastroscope was then passed through the stent and eventually into the distal CBD where the stone was seen. Under direct visualization saline assisted electrohydraulic shockwave lithotripsy was performed to fragment the stone. The stone pieces were pushed and flushed through the ampulla. Two months later, patient underwent repeat EGD. The stent was subsequently removed without any complications and today she continues to do well. This case illustrates that lithotripsy through a temporarily placed EUS-guided hepaticogastrostomy may be safe and effective approach for altered anatomy patients who cannot undergo more traditional approaches for management of complex choledocholithiasis.Figure: MRCP Showing 10.4mm CBD Stone.Figure. CBD: Stone Before Lithotripsy.Figure. CBD: Stone After Lithotripsy.

Bouveret Syndrome Missed by a Whisker: A Case Report

Background: Gallstones ileus is a rare cause of intestinal obstruction secondary to gall stone causing bilioenteric fistula. The stone commonly lodges in the distal ileum, colon or duodenum and the least common site of obstruction is the proximal duodenum/pylorus causing gastric outlet obstruction (Bouveret's syndrome). We present a case of endoscopic removal of a large gallstone impacted in the first part of duodenum. Case summary: A 61-year-old male patient, presented with symptomatic choledocholithiasis and cholelithiasis. He underwent ERC, sphincterotomy, bile duct clearence and stenting 3 months back. He was planned for cholecystectomy. Laparoscopy could not separate gall bladder from its fossa and was converted to open surgery. But open cholecystectomy was abandoned in view of dense adhesions and adherent gall bladder. He had nausea and epigastic pain for 2 weeks without jaundice or vomitting or constipation. Endoscopy was performed which showed a large cholecystoduodenal fistula on the posterior wall of first part of duodenum. Endoscopic stone retrival was attempted but failed inspite of use of snare forceps/roth net forceps. He was admitted for evaluation and reattempt under anaesthesia. He had routine blood investigations which were normal. MRCP abdomen was done which showed contracted gall bladder with calculi and wall thickening, adhered to duodenum with perilesional lymphnode. Repeat endoscopy was attempted under general anaesthesia and the stone was retrieved peicemeal using roth net forceps and basket. Conclusion: Endoscopic stone retrieval can be attempted in cases of large cholecystoduodenal fistula. The authors have none to declare.

Níveis elevados de transaminases em um caso de coledocolitíase: a importância do reconhecimento deste padrão

Relato de caso de uma mulher hígida de 34 anos de idade diagnosticada com coledocolitíase sintomática associada a elevados níveis de transaminases, sem doença hepática. Altos valores destas enzimas podem ocorrer na coledocolitíase sem outra causa de lesão hepática concomitante. Os médicos devem estar atentos a este fenômeno, a fim de se evitar investigação desnecessária e suas consequências.

Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones.

AIMTo evaluate the rate of recurrence of symptomatic choledocholithiasis and identify factors associated with the recurrence of bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) for bile duct stone disease.METHODSAll patients who underwent ERCP and EST for bile duct stone disease and had their bile duct cleared from 1/1/2005 until 31/12/2008 was enrolled. All symptomatic recurrences during the study period (until 31/12/2015) were recorded. Clinical and laboratory data potentially associated with common bile duct (CBD) stone recurrence were retrospectively retrieved from patients’ files.RESULTSA total of 495 patients were included. Sixty seven (67) out of 495 patients (13.5%) presented with recurrent symptomatic choledocholithiasis after 35.28 ± 16.9 mo while twenty two (22) of these patients (32.8%) experienced a second recurrence after 35.19 ± 23.2 mo. Factors associated with recurrence were size (diameter) of the largest CBD stone found at first presentation (10.2 ± 6.9 mm vs 7.2 ± 4.1 mm, P = 0.024), diameter of the CBD at the first examination (15.5 ± 6.3 mm vs 12.0 ± 4.6 mm, P = 0.005), use of mechanical lithotripsy (ML) (P = 0.04) and presence of difficult lithiasis (P = 0.04). Periampullary diverticula showed a trend towards significance (P = 0.066). On the contrary, number of stones, angulation of the CBD, number of ERCP sessions required to clear the CBD at first presentation, more than one ERCP session needed to clear the bile duct initially and a gallbladder in situ did not influence recurrence.CONCLUSIONBile duct stone recurrence is a possible late complication following endoscopic stone extraction and CBD clearance. It appears to be associated with anatomical parameters (CBD diameter) and stone characteristics (stone size, use of ML, difficult lithiasis) at first presentation.

Living donor liver transplantation indicated for compensated liver cirrhosis with symptomatic gallstone diseases: report of two cases.

BackgroundSurgical interventions for symptomatic gallstone disease could be dangerous in patients with severe comorbid conditions including liver cirrhosis. Here, we report our experience of living donor liver transplantation (LDLT) indicated for two patients with liver cirrhosis complicated with gallstone diseases.Case 1A 70-year-old woman with a history of hepatitis C virus infection was diagnosed as symptomatic choledocholithiasis. She had open cholecystectomy and choledochotomy with choledocholithotomy, which complicated with postoperative liver failure. Her Child-Pugh score increased from 7 to 12 points and Model for End-Stage Liver Disease (MELD) score from 11 to 36. She underwent LDLT, using the right lobe graft donated by her 47-year-old daughter. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 27.Case 2A 46-year-old man with a history of hepatitis B virus infection was diagnosed as cholecystitis. He had cholecystostomy without any complications and his Child-Pugh score remained to be 9 and MELD score 17, followed by LDLT using the right lobe graft donated by his 45-year-old wife. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 44.ConclusionLDLT is one of treatment options when patients with Child-Pugh B cirrhosis accompanied with gallstone diseases, likely to be deteriorating their liver functions in the near future.

An Endoscopic Retrograde Cholangiopancreatography-Induced Subperiostal Orbital Hemorrhage

Subperiostal orbital hemorrhage is not a complication reported in ERCP literature. We reviewed multiple cases reports or small retrospectives series of subperiostal hematoma but only one case of bilateral spontaneous orbital hemorrhage with symptoms onset immediately after ERCP; our case is then the second reporting this complication. A 38-years-old female was referred for symptomatic choledocholithiasis (painless jaundice, prurit, dark urine, acholic feces). Abdominal ultrasonography confirmed a 12 mm choledocholithiasis with 19 mm bile duct dilation. ERCP were performed for numerous lithiases difficult to extract with minimal tolerance by the patient. She had protracted valsalva on the fourth CPRE. She immediatly reported left ocular pain, diplopia and retroocular pressure as if her eye was going to pop out. Physical exam revealed left eye ptosis, tissue swelling, exophthalmia, diplopia with extremely painfull and partial eye movement. Urgent orbital contrast-enhanced computed tomography scanning was ordered. A left superior subperiosteal hemorrhage of 30 mm width by 32 mm anteroposterior by 10 mm vertical was shown, pushing inferiorly conal muscles, optical nerve and intraorbital fat resulting in grade II exophtalmia (fig 1-4). There were no nerve or vessel compromise and no active bleeding. Radiologist raised concern about an underlying orbital bone anomaly without obvious mass.Figure 1Figure 2Figure 3Blood work the day of the ERPC were; International normalized ratio 1.3, platelets 381, normal renal clairance. Thromboprophylactic heparin was suspended before the ERCP. She received 2 fresh frozen plasma to correct her minimaly increased INR after the hematoma was confirmed. The patient was treated with intraocular latanoprost (prostaglandin analog) 0.005% 1 drop hs and eye rest. She already did better the day after with partial pain resolution, minimal oblic diplopia and no other vision perturbation. Eleven days later an orbital magnetic resonance showed partial resorption of the hematoma, diminution of the mass effect with residual grade I exophthalmia and no underlying mass was shown. Patient was still jaundiced and magnetic resonance cholangiopancreatography confirmed persistence of choledocholithiasis. A subsequent ERCP was done under general anesthesia and stones were removed with mechanical lithotripsy. Six weeks later, the patient blood work was normal and she was asymptomatic. Subsequently, a 18 months follow-up orbital magnetic resonance was completely normal. In conclusion subperiostal orbital hemorrhage is an extremely rare complication of ERCP. ERCP endoscopits should all be aware of its nature because presentation can be less florid than our case and urgent surgical management may be needed to relieve vessel/vascular compromise.

Nonradiation ERCP with endoscopic biliary sphincterotomy plus papillary balloon dilation for the treatment of choledocholithiasis during pregnancy.

Endoscopic retrograde cholangiopancreatography (ERCP) is currently the treatment of choice for symptomatic choledocholithiasis in pregnant patients. We aimed to present our experience with pregnant patients who underwent nonradiation ERCP and to evaluate the safety and efficacy of a new technique. A retrospective analysis of nonradiation ERCP in 22 pregnant patients with symptomatic choledocholithiasis between January 2002 and December 2013 was performed. The bile aspiration technique with wire-guided sphincterotome was used to confirm selective biliary cannulation. Transpapillary pancreatic septotomy was performed in cases with difficult biliary cannulation (n = 3). After endoscopic biliary sphincterotomy, endoscopic papillary balloon dilation was performed with a 6- or 8-mm dilation balloon in all patients to reduce the risk of recurrent cholangitis because of residual or additional stones. Stones were extracted by balloon sweeping after dilation. All patients were followed for 6 months after the ERCP procedure. Biliary cannulation was achieved in all patients. Endoscopic papillary balloon dilation was performed with a 6-mm balloon in 17 patients and an 8-mm balloon in five patients. The stones were extracted in 18 of the 22 patients by balloon sweeping, but no stones were extracted in the remaining four patients. There were two cases of mild post-ERCP pancreatitis. All patients delivered at term, and none experienced recurrence of choledocholithiasis and/or cholangitis during the 6-month follow-up. Endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation in nonradiation ERCP is a safe and effective treatment method for symptomatic choledocholithiasis during pregnancy.

Consecutive versus separate sessions of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic choledocholithiasis

BackgroundCommon bile duct (CBD) stones are a potentially life-threatening medical condition. Patients with proven CBD stones should undergo stone extraction. The aim of this study was to evaluate whether performing endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic CBD stones in a single session reduces complications related to postponing treatment due to separate EUS and ERCP sessions, and to assess the safety in both options.MethodsA total of 151 patients with EUS-proven CBD stones, with subsequent ERCP, treated in our department between January 2005 and December 2011 were included. Complications related to the procedures or sedation and complications due to the CBD stones when EUS and ERCP were not performed in a single session were assessed and compared to complications when the two procedures were performed in one session.ResultsIn total, 149 patients of the 151 (98.7 %) had a successful ERCP. Four (5 %) patients in the separate-session group (B) had a major complication compared to none in the single-session group (A) (p > 0.05). Group B received 14 % more midazolam during ERCP than group A (p < 0.05). No sedation-related complications were noted in either group. Eleven of the 80 patients in group B (13.8 %) experienced complications while waiting for ERCP compared to none in group A (p = 0.001, OR = 2.17, CI = 1.06–4.ConclusionsEUS and ERCP done in a single session proved to be safe, with no increase in sedation- or procedure-related complications. Postponing treatment for symptomatic CBD stones exposes the patient to biliary complications, especially cholangitis.

Endoscopic retrograde cholangiopancreatography (ERCP)-related esophageal perforation in osteogenesis imperfecta

A 77-year-old woman with osteogenesis imperfecta was admitted with symptomatic choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out and mild resistance was encountered in the distal esophagus with “red out” during intubation. The duodenoscope was withdrawn and gastroscopy revealed a tear in the distal esophagus (● Fig.1). As a perforation was suspected, a nasogastric tube was deployed, intravenous antibiotics were started, and surgery was consulted. An esophagogram confirmed the esophageal leak (● Fig.2) and thoraco-abdominal computed tomography (CT) showed a 0.7-cm esophageal perforation and air– fluid collection (3cm×10cm) in the posterior mediastinum (● Fig.3). Conservative management was decided on due to clinical stability and poor operative candidacy. Within 48 hours the liver function tests normalized and parenteral nutrition was started. The day 7 esophagogram showed partial healing. Enteral feeding was started with a nasojejunal tube placed fluoroscopically. An esophagogram on day 27 showed complete healing (● Fig.4). The patient started an oral diet and was discharged with plan for elective cholecystectomy. Osteogenesis imperfecta is an autosomal dominant disorder of collagen synthesis (1 in 10000 births). Gastrointestinal manifestations in osteogenesis imperfecta are rare although spontaneous colon perforation has been reported, where histopathological examination showed absence of muscle layers in the perforated segment [1]. Murine models of osteogenesis imperfecta showed thinner esophageal submucosa and muscularis compared with wild mice [2]. ERCP-related perforations are infrequent (0.4%) and are commonly related to improper guidewire insertion or sphincterotomy [3]. Esophageal perforation in ERCP is rare and is attributed to use of sharp accessories [3,4]. This is the first reported case of esophageal perforation in osteogenesis imperfecta. We believe that perforation in our patient occurred due to abnormal esophageal submucosa and muscularis and limited view with duodenoscope. Esophageal perforations are traditionally managed surgically; however, good outcomes are reported with conservative management in smaller perforations and contained leaks [5]. The present case highlights the propensity for esophageal perforation in osteogenesis imperfecta. We recommend caution and low threshold to suspect perforation during gastrointestinal endoscopy in osteogenesis im

Common bile duct stones in infancy: A medical approach

Symptomatic choledocholithiasis in infancy is not common. It usually presents with jaundice and acholic stools and is diagnosed on abdominal ultrasonography. Favourable outcome of conservative management has been reported, but specific management guidelines are not well defined in the literature. We describe three cases using a combination of ursodeoxycholic acid and antibiotics as a treatment paradigm, which could potentially negate more invasive treatment. All three patients had ultrasonography proven choledocholithiasis with concomitant obstructive liver function test. They were treated with a combination of ursodeoxycolic acid and antibiotics. Patient 1 had an Escherichia coli urinary tract infection and was treated with oral bactrim. Intravenous amoxicillin, gentamicin and metronidazole were used for the other two patients. All three patients responded with a return to normal-coloured stools within 48 h of combination treatment. Repeat ultrasonography done within 11 days after the first study for all three patients confirmed complete resolution of choledocholithiasis. It is postulated that this improvement is as a result of a reduction in inflammation and oedema, associated with a low-grade cholangitis, following antibiotic treatment. This is coupled with improved bile flow with ursodeoxycholic acid therapy. The findings suggest the potential application of this safe, non-invasive therapeutic strategy as initial management in infants with this condition. A follow-up prospective randomised controlled trial may be an answer to prove the validity of this observation but due to the rarity of this problem, it would be a challenge to recruit sufficient number of patients.

Sp812 A Hybrid Percutaneous and Endoscopic Approach for the Complete Clearance of Gallstones from the Gallbladder and Biliary Tree

Gallstone disease is common and costly. Cholecystectomy is the preferred method of treatment. Alternatives to cholecystectomy, however, are needed in patients with high surgical risks. Available alternatives include percutaneous cholecystostomy, endoscopic retrograde cholangiopancreatography (ERCP) transpapillary gallbladder drainage, and dissolution therapy. More effective minimally invasive alternatives are needed as these approaches have limited efficacy and do not completely clear gallstones. We present a case of a 94 year old female with multiple medical co-morbidities and recurrent acute gallstone cholecystitis managed with placement of a cholecystostomy tube due to her high surgical risk. The patient continued to have multiple admissions for symptomatic choledocholithiasis despite the cholecystostomy tube, an endoscopic sphincterotomy, and interventional radiology placed internal/external catheter.

Endoscopic ultrasound-guided anterograde treatment of biliary stones following gastric bypass

Endoscopic treatment of bile duct stones in gastric bypass patients is challenging. We describe a novel method involving endoscopic ultrasound (EUS)-guided anterograde interventions. After prior experience with EUS-guided rendezvous endoscopic retrograde cholangiopancreatography (ERCP) and direct EUS-guided anterograde stenting for malignant biliary obstruction, we have attempted EUS-guided treatment of biliary stones as first-line therapy following gastric bypass. Our approach involves: (i) EUS-fine needle aspiration (FNA) puncture into an intrahepatic bile duct; (ii) EUS-guided cholangiography; (iii) guide wire advancement across the ampulla; (iv) catheter dilation of the transhepatic-transgastric access tract; (v) anterograde balloon sphincteroplasty; and (vi) anterograde advancement of stones across the ampulla using a balloon catheter. We reviewed outcomes and complications of this technique. Six patients with previous Roux-en-Y gastric bypass were referred for treatment of symptomatic choledocholithiasis. EUS-guided transhepatic puncture and cholangiography was successful in 100 %, and revealed choledocholithiasis in all patients. Tract dilation, anterograde balloon sphincteroplasty, and stone extraction were successful in four (67 %). Anterograde sphincteroplasty failed in two patients due to inability to advance the transhepatic dilation catheters. In both cases, wires were advanced down the afferent limb, and rendezvous ERCP using double-balloon enteroscopy was successful. Five patients experienced no complications. One patient in whom EUS anterograde therapy failed due to difficulty in advancing the transhepatic dilation catheter, developed a subcapsular hepatic hematoma. This was managed conservatively. Direct EUS-guided treatment of biliary stones after gastric bypass appears safe and feasible. Further studies are needed to confirm the safety and efficacy of this technique.

Preoperative MRCP to detect choledocholithiasis in acute calculous cholecystitis

PurposeThere are risks of common bile duct (CBD) stones in acute cholecystitis, and there is a move among surgeons to identify choledocholithiasis before surgery. Magnetic resonance cholangiopancreaticography (MRCP) has the potential to accurately detect choledocholithiasis in patients with acute cholecystitis. The aim of this study was to evaluate the predictive values of MRCP and elevated biochemical predictors for choledocholithiasis in patients with acute cholecystitis.MethodsBetween September 2006 and August 2008, of 84 patients with acute cholecystitis based on the diagnosis criteria of the Tokyo guidelines, 57 had MRCP preoperatively. The predictive values of six biochemical predictors for choledocholithiasis were also evaluated.ResultsOf the 57 patients, seven (12.28%) had choledocholithiasis, of whom three had CBD stones in nondilated ducts. The smallest stone detected in a dilated CBD and nondilated duct was 3.19 and 4.55 mm in diameter, respectively. None of our patients whose MRCP showed a clear CBD returned with symptomatic choledocholithiasis during the follow-up period. All biochemical predictors and CBD diameter had limited positive predictive values.ConclusionsMagnetic resonance cholangiopancreaticography is a reliable evaluation technique for the detection of choledocholithiasis. It reduces the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and prevents the risk of overlooking choledocholithiasis. No single predictor or combined markers have been found to be reliable for including/excluding the presence of choledocholithiasis.

Duration of Pain Is Correlated With Elevation in Liver Function Tests in Patients With Symptomatic Choledocholithiasis

We assessed the temporal relationship between abdominal pain and elevation in liver function tests (LFTs) in patients with acute symptomatic choledocholithiasis. Retrospective study of patients that presented within 12 hours of pain onset and were subsequently found to have choledocholithiasis. We identified 40 patients with complete medical records. Levels of aspartate and alanine aminotransferases (AST and ALT) correlated with duration of pain (Pearson correlation, r = 0.633 and 0.622 respectively, P < .001 for both); the correlation was not as strong for γ-glutamyl transpeptidase (GGT) (r = 0.326, P = .046) and was not significant for alkaline phosphatase or bilirubin. This temporal association was stronger in patients that had undergone cholecystectomy versus those with intact gallbladders (for ALT, r = 0.603 vs r = 0.311, respectively). Eighteen patients, evaluated within 6 hours of pain, had normal or minimal alterations in LFTs; transabdominal ultrasound was abnormal in 6 (sensitivity 33.3%). All had repeat LFTs within 24 hours (mean 10.3 ± 6.9 hours later) and large increases in ALT and aspartate aminotransferase levels (mean 10.5- and 6.8-fold respectively; P < .01 for both), intermediate increases in glutamyl transpeptidase levels, (mean 4-fold, P < .05), and no changes in alkaline phosphatase levels. This significant increase in LFTs was the only indication of biliary pathology before endoscopy in 11/18 patients. Increasing duration of pain is associated with increasing LFTs (particularly transaminases) in patients with acute symptomatic choledocholithiasis. Patients with normal LFTs and ultrasound upon presentation should have repeat LFTs if biliary pain is suspected. The absence of significant biochemical abnormalities within the first 24 hours makes the diagnosis of symptomatic choledocholithiasis unlikely.

The Temporal Relationship Between Duration of Epigastric Pain and Elevation of Liver Function Tests, and the Value of Repeated Testing, in Symptomatic Choledocholithiasis

The Temporal Relationship Between Duration of Epigastric Pain and Elevation of Liver Function Tests, and the Value of Repeated Testing, in Symptomatic Choledocholithiasis