Temporary Biliary Stenting Research Articles

Autoimmune Hepatitis-Primary Sclerosing Cholangitis Overlap Syndrome Complicated by Crohnʼs Disease

Purpose: Autoimmune Hepatitis-Primary Sclerosing Cholangitis overlap syndrome (AIH-PSC overlap syndrome) complicated by Crohn's disease (CD) is rare. We report one such case. A 22 year old African American female diagnosed with AIH 8 years ago was being maintained on azathioprine and prednisone with stable LFTs when her alkaline phosphatase (AP), transaminases and total bilirubin began to rise. Liver biopsy and magnetic resonance cholangiopancreatography (MRCP) confirmed worsening fibrosis and found intra and extra-hepatic ductular proliferation and stricturing, leading to her diagnosis being changed to AIH-PSC overlap syndrome. Ursodeoxycholic acid (UDCA) was added to decrease cholestasis from PSC and mycophenolate mofetil (CellCept®) was added for worsening AIH. She also underwent percutaneous transhepatic cholangiography (PTC) with temporary biliary stenting. She remained fairly stable during the next three years but then began to have persistent diarrhea, abdominal cramping and further deterioration of LFTs. Colonoscopy revealed patchy ulcerations and erythema throughout the colon and terminal ileum. Pathology report confirmed a diagnosis of CD. Prednisone was replaced with budesonide as induction therapy for CD and dose of azathioprine was increased in an attempt to use it as maintenance therapy for both CD and AIH. She continued to flare, therefore three months later, azathioprine and budesonide were both discontinued and she was started on adalimumab. Six months into therapy, she again began to flare. Methotrexate was added to optimize adalimumab's effect but her liver enzymes deteriorated. Both adalimumab and methotrexate were discontinued and she was placed on 6-mercaptopurine (6-MP). She is currently on CellCept® for AIH with stable transaminases and CD is in remission on 6-MP. A recent liver biopsy revealed cirrhosis and liver transplantation was discussed. She continues to take UDCA and has had to undergo PTC with temporary biliary stenting several times since being diagnosed with AIH-PSC overlap syndrome. AIH-PSC overlap syndrome complicated by CD has been reported in literature, but is very rarely seen in clinical practice. Successful treatment is a challenge and requires a trial of several combination immunomodulators and UDCA. PTCA or endoscopic balloon dilation with or without stenting for biliary stricturing is also frequently needed. Liver transplantation is eventually required. Medical, endoscopic, percutaneous and surgical interventions all carry risks and side effects. A very close follow up, with effective communication between the hepatologist and the IBD specialist is essential for a better outcome.

Pancreatite aguda como manifestação de linfoma de Burkitt em idade pediátrica.

Pancreatitis in children and adolescents is uncommon and its causes are more varied in this age group than in adults. A tumoral aetiology is particularly rare. We present the case of a 13-year-old boy who was admitted to our Intensive Care Unit with the diagnosis of acute pancreatitis, bilateral pleural effusion and ascites. Serial sonographic and computed tomography evaluations were suggestive of an infiltrative process of the gastric wall. Endoscopy showed an infiltrative tumor of the gastric mucosa and duodenum with a giant ulcer. Biopsies were compatible with Burkitt Lymphoma confirmed by ascitic fluid cytology and cytometry. Because of severe progressive cholestasis a temporary biliary stent was placed in the common bile duct. After staging (stage III), the patient was treated according to FAB LMB 96 chemotherapy protocol, achieving complete remission. Acute pancreatitis and cholestasis are rare presentations of lymphoma in the paediatric age group.

Primary Hodgkinʼs Lymphoma Masquerading as a Klatskin Tumor

Purpose: Cholangiocarcinoma affects 2–2.8 per 100,000 population per year, and has a 5 year mortality rate of 90%-95%. Current limitations of pre-operative tissue sampling often make a definitive diagnosis elusive necessitagting surgical exploration. We present a case of an obstructing hilar mass, intially thought to be an advanced cholangiocarcinoma, found to be a primary extraductal hilar Hodgkin's lymphoma at laparotomy. Results: A 56 year old male presented with gradual onset of painless jaundice. Initial work- up revealed: AST 464U/L, ALT 548U/L, Alk Phos1697U/L, T.Bili 7.90 mg/dL, and Direct Bili 6.00 mg/dL. Tumor markers including AFP, CEA, LDH, and CA19-9 were unremarkable. Triple phase CT abdomen revealed a common hepatic duct filling defect with intrahepatic ductal dilation without extrahepatic dilation, later confirmed by MRCP. ERCP was then performed revealing a moderate sized stricture involving the common hepatic duct and a short portion of both intrahepatic ducts consistent with a Bismuth II tumor. Brushings were negative for malignancy and temporary biliary stenting was performed for decompression while surgical consultation was obtained for definitive diagnosis. Exploratory laparatomy with choledochoscopy did not reveal cholangiocarcinoma, but rather an obstructing hilar lymph node causing extrinsinc compression of the common hepatic duct. Biopsy revealed lymphocytic rich Hodgkin's lymphoma. Resection and bilateral hepatico-jejunostomy was averted, and the patient was referred to Oncology for treatment. Conclusions: Primary extranodal non-Hodgkin lymphoma of the extrahepatic bile duct mimmicking Klatskin tumor has rarely been reported. Though cholangiocarcinoma accounts for 60–80% of Klatskin tumors; other causes of biliary tree obstruction such as lymphoma should be entertained as treatment may be non-surgical. [figure 1]Figure 1

Long-term follow-up after biliary stent placement for postoperative bile duct stenosis

Background: The outcome of temporary biliary stent placement for postoperative bile duct stenosis was retrospectively evaluated with the main aim of assessing long-term complications after stent removal. Methods: ERCP was performed between 1981 and 1991 in 74 patients with postoperative bile duct stenoses. Two 10F stents were inserted for a maximum of 12 months with stent exchange every 3 months to avoid cholangitis caused by clogging. Results: Stent insertion failed in 11 patients with complete and 4 patients with incomplete biliary obstruction. Early complications occurred in 14 patients (19%) including 2 deaths. Therefore 57 patients were included in the stent phase of the study. In 10 patients the referring physician did not adhere to the treatment protocol, and nonelective stent exchange for jaundice and/or cholangitis was necessary in 7 (70%). Of the 47 patients treated according to protocol, complications developed in 40% during the period with stents in situ. Stents were eventually removed in 44 patients who were subsequently followed for a median of 9.1 years. Late complications developed in 15 patients (34%) including recurrent stenosis in 9 (20%). All cases of recurrent stenosis occurred within 2 years of stent removal. Conclusions: Endoscopic treatment is feasible in 80% of patients who undergo an ERCP for postoperative bile duct stenosis. After stent insertion and during the time with stents in situ, complications occur at a significant rate but are usually mild or reflect the patient's underlying condition. After stent removal, recurrent stenosis develops in 20% of patients within 2 years of stent removal. Endoscopic treatment should be the initial management of choice for postoperative bile duct stenosis. (Gastrointest Endosc 2001;54:154-61.)

Temporary and long term biliary stenting for retained common bile duct stones in an irish cohort

Temporary and long term biliary stenting for retained common bile duct stones in an irish cohort

Biliary-shunt fistula following transjugular intrahepatic portosystemic shunt placement

Sepsis following the placement of a transjugular intrahepatic portosystemic shunt (TIPS) has been reported in up to 10% of cases. This report describes an unusual case of polymicrobial gram-negative sepsis after placement of TIPS associated with a cholangiographically documented fistulous connection between the biliary tree and shunt. The patient was treated with temporary biliary stent placement, endoscopic sphincterotomy, and broad-spectrum antibiotics with rapid closure of the fistula and resolution of sepsis. In the absence of hemobilia, it is hypothesized that flow through the fistula allowed bilious contamination of the systemic circulation and subsequent inoculation with enteric flora. The prevalence of biliary-vascular fistula after placement of TIPS is unknown. It may be a previously unsuspected source of sepsis after placement of TIPS and is likely to be overlooked unless endoscopic retrograde cholangiopancreatography is performed. (Gastroenterology 1996 Nov;111(5):1353-7)