Treatment Of Biliary Obstruction Research Articles

Homoeopathic Management of Acute Cholangitis in a Case of Adenocarcinoma of Gall Bladder with Metastasis: A Case Report

AbstractAcute cholangitis is a bacterial infection superimposed on an obstruction of biliary tree from a gall stone, neoplasm or stricture. The biliary obstruction is most commonly caused by choledocholithiasis benign or malignant stricture of the bile duct or hepatic ducts, pancreatic cancer, ampullary adenoma or cancer, porta hepatis tumour or metastasis, biliary stent obstruction (due to microbial biofilm formation, biliary sludge deposition and duodenal reflux of food content), primary sclerosing cholangitis and amyloid deposition in the biliary system. Classically, patients present with high fever persisting for more than 24 hours, abdominal pain and jaundice (Charcot's triad). The right upper quadrant abdominal (RUQ) pain is generally mild. When the cholangitis becomes more severe, patients become hypotensive and confused (Reynold's pentad). Charcot's triad has low sensitivity (26.4%) and high specificity (95.9%). Although the presence of Charcot's triad is suggestive of acute cholangitis, it is not diagnostic. Charcot's triad is present in 26.4 to 72% of patients with acute cholangitis. TG07 diagnostic criteria for acute cholangitis also do not have enough sensitivity and specificity and its severity criteria are also not suitable for clinical use. Antibiotics, intravenous fluid, Vitamin K supplementation and biliary drainage are the options available in conventional mode of treatment for acute cholangitis. Presented here is one case report of acute cholangitis in a patient of adenocarcinoma of gall bladder with metastasis. The case was treated using classical method of homoeopathy with complete improvement in clinical and laboratory parameters of acute cholangitis.

S1786 Pancreatic Metastasis Secondary to the Masters of Costumes, Renal Cell Carcinoma

Introduction: Renal cell carcinoma (RCC) has been one of the most studied cancers, and its metastatic capabilities are well documented in literature. RCC accounts for 80%-85% of primary renal neoplasm. Approximately 25% of individuals have distant metastases at the time of diagnosis. Its metastatic capabilities continue to be one of the most challenging aspects of the disease. Metastasis to the pancreas has been described in about 2%-5% of all malignant pancreatic tumors. Case Description/Methods: Case of an 80-year-old man with medical history of Stage IV RCC, treated with immunotherapy. Treatment was discontinued due to adverse effects. Patient presents to the ER with a complaint of intractable pruritus. On laboratory values, found with elevated liver enzymes and total bilirubin, with a mixed hepatocellular and cholestatic pattern, reason why gastroenterology service was consulted. Physical examination showed generalized jaundice. Abdominal CT scan showed multiple intrabdominal lesions, including in the pancreas, causing intra and extrahepatic ductal dilation. MRCP showed multiple intrabdominal masses encasing the common bile duct, causing intra and extrahepatic biliary tree and distal pancreatic duct dilation. Concern of a primary pancreaticobiliary malignancy arose. On EGD, multiple gastric and duodenal clean base ulcers and 2 large pedunculated polyps in the second portion of the duodenum removed using hot snare polypectomy technique, and random biopsies on gastric and duodenal ulcers taken. On EUS, a large hyperechoic vascular lesion was observed in the pancreatic head, infiltrating the intrapancreatic bile duct. Another large 3.3 cm x 3.0 cm vascular mass at the gastro-hepatic ligament was observed. Biopsies from duodenal ulcer, duodenal polyp, and pancreatic mass were consistent with metastatic clear cell neoplasm as seen in RCC. ERCP was made to place a fully covered metallic stent at CBD stricture caused by extrinsic compression. Discussion: RCC is the most common renal tumor. Up to 25% of cases present with advanced disease at diagnosis. Our patient presents with multiple intrabdominal masses causing biliary tree and pancreatic duct obstruction. Advanced endoscopic techniques and cross-sectional images play an essential role in the diagnosis and management of pancreaticobiliary pathologies. Other etiologies such as metastatic RCC may mimic primary pancreaticobiliary malignancies. In this case, advanced endoscopic modalities were used for tissue diagnosis and management of metastatic disease.

S1818 Rare Sequelae of Obstructive Jaundice: Hyperferritinemia and Bile Cast Nephropathy

Introduction: Obstructive jaundice occurs due to a physical blockage in the biliary outflow tract or external compression. While jaundice and scleral icterus are common symptoms initially, long term sequelae include severe systemic manifestations from the buildup of various compounds normally excreted in bile such as bilirubin. Case Description/Methods: A 67-year-old male smoker presented with 3 weeks of pruritus, acholic stools, dark urine, nausea, vomiting, and 20-pound weight loss. Physical exam was notable for jaundice and scleral icterus, LUQ and epigastric tenderness to palpation, but lacked hepatosplenomegaly, ascites or other stigmata of cirrhosis. Liver function tests showed AST 486 IU/L, Alk Phos 1419 IU/L, Alt 600 IU/L, and total bilirubin >30.0 mg/dL with direct bilirubin >10.0 mg/dL. Ferritin was >7500 ng/mL with decreased transferrin of 159 mcg/dL. Hepatitis panel and malignancy/autoimmune markers were negative. CMP showed BUN 74 mg/dL, and creatinine 5.1 mg/dL with 2+bilirubin on urinalysis and microscopic analysis showing pigmented renal tubular cells, bilirubin crystals, and waxy casts suggestive of ATN due to bilirubin damage and possible CKD given waxy casts (Table). CT abdomen reported severe intra and extra hepatic biliary duct dilation with CBD of 17 mm and abrupt tapering with pancreatic head fullness confirmed with MRCP. On day 2, ERCP showed a tight 15mm distal biliary stricture. A small sphincterotomy followed by balloon dilation allowed for placement of a CBD stent with excellent drainage of dark green bile. Following ERCP, patient had a drop of liver function tests and ferritin levels, gradual improvement in BUN and creatinine, and was discharged in stable condition on hospital day 6. On day 16, EUS revealed a hypoechoic area within the periampullary area with atypical cells in brushings collected during repeat ERCP (Figure). Discussion: Iron and iron binding proteins have been shown to be excreted in bile, primarily in iron excess. Our patient showed a large increase in ferritin signifying the potential role of biliary excretion of excess ferritin, with unknown ramifications. Additionally, severe biliary tree obstruction led to markedly elevated bilirubin, overwhelming renal clearance leading to severe tubular damage. With alleviation of obstruction, there was a steady decrease in ferritin and return to normal baseline renal function. Further research is needed to clarify both the consequences of excess ferritin in biliary obstruction and the significance of excess bilirubin in renal injury.Figure 1.: a) Ampulla prior to ERCP on day 2 shows no periampullary abnormality. b) Day 16 - Endoscopic Ultrasound showing narrowing of distal common bile duct with hypoechoic intraductal area. c) Bile casts and bilirubin crystals seen on microscopy. Table 1. - Patient’s Laboratory test results on and post admission Laboratory Values Reference Range Day 1 Day 5 (3 days post-ERCP) Day 21 AST 13 – 39 IU/L 486 187 18 ALT 7 – 52 IU/L 600 315 27 Alkaline Phosphatase 34 – 104 IU/L 1419 886 160 Total Bilirubin 0.3 - 1.2 mg/dL >30.0 13.0 4.4 Albumin 3.5 - 5.2 g/ 3.0 2.9 3.4 BUN 7 – 25 mg/dL 74 64 18 Creatinine 0.5 - 1.2 mg/dL 5.1 2.90 1.01 WBC 4 – 11 K/cmm 13.8 17.7 10.1 Hgb 13.7 - 17.5 g/dL 11.9 9.4 8.5 Ferritin 24 – 336 >7500 4677 976 Transferrin 300 to 360 mcg/dL 159 233 Iron 50 - 182 ug/dL 126 61 Iron Saturation 57% 19% TIBC 250 – 450 ug/dl 233 326 Urine Bilirubin Negative 2+ Negative Urobilinogen 0.0 - 2.0 EU/dL 4.0 < 2.0 PT 9.1 - 13.2 sec 26.6 12.8 PTT 23.3 - 36.6 SEC 42.0 33.0 INR 0.8 - 1.2 2.3 1.1 Alpha-1-Antitrypsin (ATT) 83 – 199 mg/dL 256 Ceruloplasmin 18– 36 mg/dL 51 Carcinoembryonic Antigen (CEA) 0.0 - 3.0 ng/mL 3.9

Nimotuzumab combined with gemcitabine versus gemcitabine in K-RAS wild-type locally advanced or metastatic pancreatic cancer: A prospective, randomized-controlled, double-blinded, multicenter, and phase III clinical trial.

LBA4011 Background: Pancreatic cancer is one of the most lethal malignancies diagnosed at an advanced stage, and current treatment regimens are ineffective, with only 6-8 months of median overall survival (mOS). The present study aims to assess the clinical efficacy and safety of nimotuzumab (anti-EGFR humanized monoclonal antibody) combined with gemcitabine in K-Ras wild-type patients with locally advanced or metastatic pancreatic cancer. Methods: Patients with locally advanced or metastatic pancreatic cancer were randomized to receive nimotuzumab (400 mg, every one week) followed by gemcitabine (1000 mg/m2 on days 1, 8, and 15, every four weeks), or placebo plus gemcitabine until progression or unacceptable toxicity. The primary endpoint was overall survival (OS), and secondary endpoints included progression-free survival (PFS), objective response rate (ORR), and safety. Use restricted mean survival time (RMST)-Log function to analyze the survival benefits when the proportional hazards assumption is untrue. Results: A total of 92 Chinese patients were randomly assigned to the nimotuzumab- gemcitabine (n = 46) or placebo-gemcitabine group (n = 46). In the full analysis set (FAS, n = 82), the mOS was significantly longer in the nimotuzumab-gemcitabine group (10.9 vs. 8.5 months, p = 0.025 by RMST-Log test, hazard ratio [HR], 0.50, 95% Confidence Interval [CI], 0.06 to 0.94). The one-year survival rate was 43.6% in the nimotuzumab-gemicitabine group vs. 26.8% in the placebo-gemicitabine group, and 13.9% vs. 2.7% at three years. Subgroup analyses showed more survival benefit in patients without treatment of biliary obstruction (11.9 vs. 8.5 months, HR = 0.54, 95%CI 0.33-0.88, p = 0.037) and no surgical history (15.8 vs. 6.0 months, HR = 0.40, 95%CI 0.19-0.84). The median progression-free survival (mPFS) was 4.2 months in the nimotuzumab-gemicitabine group, as compared with 3.6 months in the placebo-gemicitabine group (HR = 0.56; 95% CI, 0.12 to 0.99; p = 0.013 ); Patients without treatment of biliary obstruction had significantly longer PFS (5.5 vs. 3.4 months; p = 0.008 ). No statistical difference in the ORR between the two groups ( p &gt; 0.05). Nimotuzumab was safe and the incidence of adverse events in the nimotuzumab-gemicitabine group is similar to placbo-gemicitabine group. The most common grade 3 TRAEs in Nim-Gem group were neutropenia (11.1%), leukopenia (8.9%) and thrombocytopenia (6.7%). No grade 4 TRAEs. Conclusions: Nimotuzumab combined with gemcitabine increases OS and PFS in patients with K-Ras wild-type locally advanced or metastatic pancreatic cancer, particularly for those without treatment of biliary obstruction. The safety profile of nimotuzumab is similar to placebo. Clinical trial information: 02395016.

Diagnostic Inflammation Biomarkers for Prediction of 30-Day Mortality Rate in Acute Cholangitis.

Background:Acute cholangitis (AC) is an acute inflammation and infection of the biliary tract, a potentially life-threatening infection, which is usually associated with biliary tree obstruction and impairment of bile flow from the liver to the duodenum. AC is classified by severity from mild, moderate to severe infection (grade I to III, respectively).Methods:This study recruited a retrospective cohort from Jan 2015 to July 2018. Overall, 294 patients of age ≥ 18 years with AC were enrolled. The study was conducted according to the World Medical Association Declaration of Helsinki. Demographic and laboratory data were collected for analysis. T-Bilirubin and other laboratory results were collected and analyzed using independent T-test and ANOVA for continuous values and multivariate COX regression for survival analysis for identifying independent factors for early mortality. The cut-off threshold of T-bilirubin was determined by calculating the area under the receiver operating characteristic (ROC) curve.Results:There were 213 male and 81 female patients and mean age ± SD of patients was 49.57 ± 16.1 and 56.12 ± 20.18 respectively. 31.9% patients were found older than 60 years of age and 35% patients were found between 30–45 years of age. T-bilirubin and length of hospital stay (LOS) were found statistically significant (P < 0.05) in relation to mortality in AC patients. The area under ROC curve for T-bilirubin level (P = 0.017, OR = 1.010) was 0.717 (95% CI, 6.25–168.9) and this is consistent with the Cut-off point for more than or equal to 38.6 µmol/L (2.26 mg/dL).Conclusions:In this study, T-bilirubin level is found to be significantly related to short-term mortality in AC. Further studies are still needed with larger cohorts to shed more light on these findings.Highlights:Herein, we report a retrospective observational study aiming to evaluate biomarkers contributing to mortality in AC and to determine the cut-off diagnostic levels that could be easily used in emergency setting. Overall, 294 patients of age ≥ 18 years with AC were enrolled. The study was conducted according to the World Medical Association Declaration of Helsinki and approved by Institutional Review Board (IRB) with approval: MRC-01-20-823 at Hamad Medical Corporation (HMC). Demographic and laboratory data were collected for analysis. Total-Bilirubin and other laboratory results were collected and analyzed using independent T-test and ANOVA for continuous values and multivariate COX regression for survival analysis for identifying independent factors for early mortality. The cut-off threshold of T-bilirubin was determined by calculating the area under the receiver operating characteristic (ROC) curve. There were 213 male and 81 female patients and mean age ± SD of patients was 49.57 ± 16.1 and 56.12 ± 20.18 respectively. 31.9% patients were found older than 60 years of age and 35% patients were found between 30-45 years of age. T-bilirubin and length of hospital stay (LOS) were found statistically significant (P < 0.05) in relation to mortality in AC patients. The area under ROC curve for T-bilirubin level (P = 0.037, OR = 1.010) was 0.717 (95% CI, 6.25–168.9) and this is consistent with the Cut-off point for more than or equal to 38.6 μmol/L (2.26 mg/dL).

S3483 Recurrent Pyogenic Cholangitis

Introduction: Recurrent pyogenic cholangitis is a chronic infective process characterized by recurrent attacks of acute bacterial cholangitis, in the setting of intrahepatic biliary ductal dilation and strictures, traditionally seen in South East Asia. Case Description/Methods: We present a 39 year old female who immigrated to the United States from Burma referred to gastroenterology clinic for abnormal liver tests and computed topography (CT) scan. Patient also reported intermittent right upper quadrant abdominal pain, fatigue and decreased appetite. Labs were significant for mildly elevated aspartame transferase (AST), alanine transferase (ALT) and alkaline phosphatase (AP). CT and magnetic resonance cholangiopancreatography (MRCP) were notable for intrahepatic biliary ductal dilation with multiple non-enhancing filling defects suggestive of stones or sludge, most pronounced in the left lobe of the liver and left hepatic lobe atrophy. Common bile duct was non-dilated without stones, sludge, wall thickening or abnormal enhancement. Liver elastography was performed which revealed cirrhosis. Patient did not have evidence of acute infection at this time but overall clinical presentation was consistent with recurrent pyogenic cholangitis. Discussion: Treatment options for recurrent pyogenic cholangitis include antibiotic therapy with signs of sepsis, removal of extrahepatic biliary stones via endoscopic retrograde cholangiopancreatography, decompression of intrahepatic biliary system via percutaneous biliary drainage and less likely surgical removal of diseased liver segment and potential liver transplantation. After discussion between an advanced endoscopist, general gastroenterologists, interventional radiologists and surgeons, she was started on ursodeoxycholic acid with plan for antibiotic therapy if evidence of acute infection. She will continue surveillance MRCP every 6 months for evaluation of hepatocellular carcinoma and cholangiocarcinoma.Figure 1.: Patient's CT image demonstrating intrahepatic biliary ductal dilation with hyperdense material concerning for biliary sludge, chronic obstruction of the left intrahepatic biliary tree and left hepatic lobe atrophy.

Personalized Endoscopy in Complex Malignant Hilar Biliary Strictures.

Malignant hilar biliary obstruction (HBO) represents a complex clinical condition in terms of diagnosis, surgical and medical treatment, endoscopic approach, and palliation. The main etiology of malignant HBO is hilar cholangiocarcinoma that is considered an aggressive biliary tract’s cancer and has still today a poor prognosis. Endoscopy plays a crucial role in malignant HBO from the diagnosis to the palliation. This technique allows the collection of cytological or histological samples, direct visualization of the suspect malignant tissue, and an echoendoscopic evaluation of the primary tumor and its locoregional staging. Because obstructive jaundice is the most common clinical presentation of malignant HBO, endoscopic biliary drainage, when indicated, is the preferred treatment over the percutaneous approach. Several endoscopic techniques are today available for both the diagnosis and the treatment of biliary obstruction. The choice among them can differ for each clinical scenario. In fact, a personalized endoscopic approach is mandatory in order to perform the proper procedure in the singular patient.

Bile accelerates carcinogenic processes in pancreatic ductal adenocarcinoma cells through the overexpression of MUC4

Pancreatic cancer (PC) is one of the leading causes of mortality rate globally and is usually associated with obstructive jaundice (OJ). Up to date, there is no clear consensus on whether biliary decompression should be performed prior to surgery and how high levels of serum bile affects the outcome of PC. Therefore, our study aims were to characterise the effect of bile acids (BAs) on carcinogenic processes using pancreatic ductal adenocarcinoma (PDAC) cell lines and to investigate the underlying mechanisms. Liquid chromatography-mass spectrometry was used to determine the serum concentrations of BAs. The effects of BAs on tumour progression were investigated using different assays. Mucin expressions were studied in normal and PDAC cell lines and in human samples at gene and protein levels and results were validated with gene silencing. The levels of BAs were significantly higher in the PDAC + OJ group compared to the healthy control. Treating PDAC cells with different BAs or with human serum obtained from PDAC + OJ patients enhanced the rate of proliferation, migration, adhesion, colony forming, and the expression of MUC4. In PDAC + OJ patients, MUC4 expression was higher and the 4-year survival rate was lower compare to PDAC patients. Silencing of MUC4 decreased BAs-induced carcinogenic processes in PDAC cells. Our results show that BAs promote carcinogenic process in PDAC cells, in which the increased expression of MUC4 plays an important role. Based on these results, we assume that in PC patients, where the disease is associated with OJ, the early treatment of biliary obstruction improves life expectancy.

S1605 Recurrent Right Upper Quadrant Pain: An Atypical Presentation

INTRODUCTION: Right upper quadrant (RUQ) pain is a common presentation in the ED however when labs are unremarkable but presentation is suggestive of cholangitis this can present a diagnostic dilemma. CASE DESCRIPTION/METHODS: A 51 yo South Asian male was admitted with acute RUQ abdominal pain and fevers for the past week. The pain was sharp, intermittent, 10/10, radiated to right shoulder and worse with deep inspiration. He reported a fever of up to 103F. This was associated with non-bloody emesis. He denied a history of gallbladder disease, change in stool, peptic ulcer disease or unintentional weight loss. He stated that he had multiple similar episodes over the past few years. On physical exam, vitals were BP 124/71, HR 69, T 96.9F and he had RUQ abdominal pain. Lab work was as follows: WBC (5 × 103/uL), Total BR (0.5 mg/dL), ALP (83 U/L), AST (40 U/L), and ALT (57 U/L). He had a CT two months prior to admission for similar presentation with findings of hepatic steatosis. Due to severity of abdominal pain, MRCP was done demonstrating dilatation of central and segmental intrahepatic biliary ducts with a linear filling defect in the distal common bile duct. Empiric antibiotics were started. Subsequent ERCP showed a severely dilated common bile duct and common hepatic duct, with biliary sludge which was removed on balloon sweep. CBD was successfully dilated and transpapillary sphincteroplasty was performed to allow better biliary drainage and to reduce future risk of recurrence. Antibiotics were continued after discharge for total of 10 days as well as ursodiol to reduce recurrence of stone and sludge formation. Review of outside records confirmed multiple episodes of cholangitis for which patient underwent ERCP. DISCUSSION: We present a case of recurrent pyogenic cholangitis with unremarkable labs on presentation despite finding of a filling defect on MRCP. It is characterized by intra-biliary stone formation due to bile stasis leading to biliary tree strictures and obstruction with recurrent attacks of cholangitis. It is most commonly seen in people who are from Southeast Asia with a peak prevalence in third and fourth decades of life. This case reflects the importance of quick diagnostic intervention in a patient with history of recurrent pyogenic cholangitis who initially presented with fever, abdominal pain, and normal labs on presentation. In particular, if suspicion is high imaging is necessary to ensure timely diagnosis and improve patient outcomes.

Design and evaluation of a novel anti-reflux biliary stent with cone spiral valve.

Endoscopic placement of biliary stent is a well-established palliative treatment for biliary obstruction. However, duodenobiliary reflux after stent placement has been a common problem which may lead to dreadful complications. This paper designed a novel anti-reflux biliary stent with a cone spiral valve. Fluid-Structure Interaction (FSI) simulations were established to evaluate the efficiency of the anti-reflux stent comparing with a clinically applied standard stent. According to the stress distribution of the valve, the fatigue performance in the stress concentration area was analyzed. The results show that when the antegrade flow through the valve, the cone spiral valve could stretch and open to realize adequate drainage under the normal physiological pressure of biliary tract; When the duodenal reflux through the valve, the valve would be compressed and close with a result of nearly zero at the outlet flow rate. Furthermore, the anti-reflux stent achieved improved radial mechanical performance with 2.7 times higher radial stiffness than standard stent. Finite element analysis (FEA) also indicates that compared with the standard stent, the addition of the anti-reflux valve had little negative effect on flexibility of the stent. Fatigue analysis results showed that the valve was reliable. This research provides the new stent with a cone spiral valve and proves that it is technically feasible and effective for preventing the duodenobiliary reflux while ensuring the antegrade bile flow without compromising the other biomechanical performances.

Effect of vitamin C inhibiting liver fibrosis and lipid peroxidation in biliary obstruction of Wistar rats

Background: The aim of this study was to evaluate the potential inhibiting effects of vitamin C as an antioxidant against liver fibrosis and lipid peroxidation in the bile duct ligation- induced biliary obstruction of Wistar rats.Methods: A total of 25 male Wistar albino rats were divided into five groups: sham operated, control (bile duct ligation/BDL) without given vitamin C, BDL with vitamin C 75 mg, BDL with vitamin C 150 mg, and BDL with vitamin C 225 mg. Each group contained 5 animals. Vitamin C was given orally on day 3 after operation and after 14 days following vitamin C administration, all animals were performed laparotomy to obtain liver tissue samples for histopathological investigation of liver fibrosis and blood samples for malondialdehyde (MDA) as lipid peroxidation measurement.Results: The changes demonstrating hepatic fibrosis including moderate to markedly thickened wall of central veins, localized to diffuse perisinusoidal fibrosis, enlarged portal track, increased number of septa, and thickened width of septa were observed in BDL groups. MDA measurement were also observed in all groups. Treatment of biliary obstruction in BDL groups with vitamin C given orally attenuated liver damage. Both the MDA measurement and histopathologic investigation of hepatic fibrosis were observed to be reduced with the vitamin C treatment.Conclusions: Our data indicate that vitamin C inhibited liver fibrosis and lipid peroxidation in bile duct ligation-induced biliary obstruction of Wistar rats.

Congenital biliary web- a rare cause of obstructive jaundice in an infant: A case report

Background: Congenital biliary web of the extra-hepatic biliary tree is becoming exceedingly rare cause of obstructive jaundice in children. Case Presentation: We report a case of 5-month-old male baby who presented with acholic stools and persistent jaundice since birth. Magnetic resonance cholangiopancreatography (MRCP) showed contracted gall bladder and focal narrowing at mid portion of the common bile duct (CBD) with proximal dilatation of biliary channels. On exploration, a complete web was found just proximal to the confluence of cystic duct and common hepatic duct causing complete obstruction of biliary tree. A Roux-en-Y hepatico-jejunostomy was done. Postoperative recovery was uneventful. Conclusion: We conclude that congenital biliary web is a rare entity and should be considered in the dif­ferential diagnosis of biliary atresia.

Acute gallbladder torsion: computed tomography and magnetic resonance imaging findings.

An 88‐year‐old female presented to emergency with a 3‐h history of severe, colicky epigastric and right upper quadrant pain radiating to the lower abdomen with associated nausea and vomiting. Initial observations revealed normal temperature and heart rate but hypertension with a systolic blood pressure of 180 mmHg. On examination the abdomen was soft and non‐distended with a tender, palpable mass in the right upper quadrant. Blood tests showed an elevated white cell count (14.2 × 109/L), and mildly deranged liver function tests with a normal bilirubin (18 μmol/L). Abdominal computed tomography scanning was requested, which revealed a markedly distended gallbladder with moderate pericholecystic fluid but no cholelithiasis. The intra‐ and extrahepatic biliary tree was dilated with the common bile duct measuring 10 mm in the pancreatic head but no obstructing lesion or stone was visible. Initial management was commenced, including analgesia, intravenous fluid resuscitation and broad spectrum intravenous antibiotics. Due to the imaging findings suggesting distal biliary tree obstruction of unclear aetiology, contrast enhanced magnetic resonance imaging (MRI) scanning was performed prior to cholecystectomy. MRI findings consisted of a distended and thick‐walled gallbladder with reduced signal along the posterior gallbladder wall and a 2‐mm calculus at the gallbladder neck. Gallbladder orientation was abnormal with the fundus situated infero‐medial to Hartmann's pouch. Biliary tree and pancreatic ductal dilatation to the ampullary level was again observed (13 mm proximal common bile duct [CBD]) but no obstructing common bile duct calculus or peri‐ampullary mass was identified (Fig. 1). At laparoscopic cholecystectomy a gallbladder torsion was observed with associated haemorrhagic necrosis but no gallbladder perforation (Fig. 2). Following decompression and de‐torsion, surgery proceeded uneventfully, histological examination was consistent with acute gangrenous cholecystitis with no cholelithiasis. The patient recovered well from surgery and was discharged home on post‐operative day 2.

Groove pancreatitis treated by duodenal and biliary bypass

Groove pancreatitis is a type of pancreatitis where inflammation occurs in the “groove area” which is the narrow space surrounded by the duodenum, head of the pancreas and common bile duct, where lymph nodes, blood vessels and pancreatic duct exist. Groove area inflammation causes duodenal stenosis/obstruction, narrowing of the extrahepatic biliary tree and sometimes pancreatitis. The exact etiology of the disease is not well understood but Santorini duct obstruction (congenital or acquired) may be associated with inflammation of the groove area, which is partly caused by excessive alcoholic intake or gastric/duodenal peptic ulcer in adults. We report a very rare pediatric case of groove pancreatitis. The imaging findings were typical for groove pancreatitis and the bypass operation to release duodenal stenosis and extrahepatic biliary tree obstruction was performed instead of doing pancreaticoduodenectomy often done in adult cases. Groove pancreatitis is a rare disorder and a pediatric case is quite rare but pediatric surgeons should keep in mind this rare disorder when we meet the case with biliary dilatation and/or duodenal stenosis.

Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction

Background: Biliary tree obstruction and consequent jaundice occur in 70%–90% of these patients and have important consequences mainly for the patient's quality of life, morbidity, and overall mortality. Percutaneous transhepatic biliary drainage (PTBD) is an excellent palliative procedure to drain the bile ducts in malignant obstruction. We compared left- and right-sided approach in relief of malignant obstruction. The most common causes of malignant biliary obstruction (MBO) include pancreatic adenocarcinoma, hilar cholangiocarcinoma, ampullary/duodenal adenocarcinoma, gallbladder adenocarcinoma, lymphoma, and compressive metastatic peri-portal lymph node Materials and Methods: This study was a prospective, hospital-based study performed for 2 years from 2016 to 2018. PTBD was performed either through right in 16 patients or left approach in 15 patients. Two approaches were compared in terms of clinical and technological success, changes in laboratory data, internalization and survival. Results: (1) Rate of technological success was 100%. (2) There was a significant reduction in bilirubin, alanine transaminase (ALT), and alkaline phosphatase (ALP) levels after the procedure in both the approaches, but the decrease was more in the right-sided approach. Only the decrease in bilirubin levels was statistically significant. The decrease in albumin was attributed to the progression of the disease. (3) Clinical success was seen in 93.33% and 93.75% in left- and right-sided approach. (4) Internalization was done in 86.67% patients in the left-lobe approach, while as in right-lobe approach, it was done in 93.75% patients. Conclusion: PTBD causes a significant reduction in the bilirubin level, irrespective of the amount of liver drained or the type of drainage (external/internal). In our study, the reduction in bilirubin, ALT and ALP was more in the right-lobe approach. However, only reductions in levels of bilirubin were statistically significant.

Clinical presentation, diagnosis and staging of cholangiocarcinoma.

Cholangiocarcinoma (CCA) is a heterogeneous group of tumours, derived from cells of the biliary tree, which represent the second most frequent primary liver tumour. According to the most recent classifications, CCA can be subdivided into intrahepatic (iCCA) and extrahepatic (eCCA) which include perihilar (pCCA) and distal (dCCA) CCA. CCA are usually identified at advanced stages, when the primary tumour grows enough to produce a large liver mass or when jaundice has developed because of biliary tree obstruction. The ongoing challenges in the identification of risk factors and definition of a specific population at higher risk of developing CCA are the main challenges for the development of screening programs. Therefore, late diagnosis remains an unresolved issue in CCA. Imaging plays an important role in the detection and characterization of CCA, helping with radiological diagnosis, guiding biopsy procedures and allowing staging of the tumour. This review focuses on clinical presentations and diagnosis and staging techniques of CCA.

Survival analysis pattern of patients treated with biliary metallic stent versus patients treated with surgical procedures for hepato-biliary malignancies in a rural tertiary care centre in South India

Background: Tumors of the biliary tract show spectrum ranging from benign to malignant lesions. Only 20% of tumors are resectable at the time of presentation. The operative mortality was approximately 5 to 20%. The morbidity rate associated with the surgery is approximately 65%. Options for palliative therapy of biliary tree obstruction include the surgical bypass, percutaneous external drainage/stenting and endoscopic stenting. The aim was to compare the survival pattern of patients treated with biliary Self Expandable Metallic Stents (SEMS) as a palliative procedure to that of patients treated by curative surgery.Methods: This was a retrospective study. 6-months survival pattern were analysed in 20 patients treated by SEMS and compared with that of 10 patients treated with plastic biliary stents followed by curative surgery.Results: Survival pattern analysis was done for all 20 patients with SEMS. 7 patients were in &gt;1-year survival, 5 were in &gt;6months survival, 6 expired within 6months, 2 patients were lost to follow up. Survival pattern was compared with 10 patients who had plastic stents followed by curative surgery. Only 1 patient had survival rate &gt;1year post-surgery, 5 patients expired post-surgery in &lt;6months, 2 patients expired few weeks after plastic stent deployment, 2 patients were lost to follow up.Conclusions: In patients with biliary malignancies with obstruction, biliary SEMS followed up by palliative chemotherapy had better survival rate than patients who had plastic stents followed up with curative surgical procedures.

Single Cause, Dual Presentation: Inferior Pancreatico-duodenal Artery Pseudoaneurysm as a Cause of Hemorrhagic Shock and Obstructive Jaundice

Pseudoaneurysm of the inferior pancreaticoduodenal artery (IPDA) is very rare. We report the case of a patient with hemorrhagic shock secondary to a bleeding pseudoaneurysm of the IPDA, also causing obstructive jaundice by virtue of its size and location. To our knowledge, this is the first such reported case in the United States. A 45-year-old male with history of iron deficiency anemia, chronic pancreatitis and alcohol abuse presented with severe right upper quadrant (RUQ) abdominal pain for 1 week. On presentation, vitals were stable and physical examination revealed RUQ abdominal tenderness and scleral icterus. Laboratory study showed hemoglobin 6.1 g/dl, alkaline phosphatase 416U/L, GGT 230 U/L, AST 76 U/L, ALT 132 U/L, total bilirubin 4.4 mg/dl, and direct bilirubin 3.4 mg/dL. Computed tomography (CT) of the abdomen with intravenous contrast showed a pseudoaneurysm arising from the IPDA (6.5x4.1x4.3 cm), acute on chronic pancreatitis and obstruction of biliary tree due to mass effect from pseudoaneurysm, marked intra and extrahepatic biliary dilation with the common bile duct measuring 17 mm and distended gallbladder. Mesenteric angiography also revealed the aneurysm but not amenable to embolization. The patient's abdominal pain worsened and developed hemorrhagic shock requiring additional resuscitation. Stat CT angiography showed increased size of the pseudoaneurysm, and a new hyperdense material within the small bowel loops. Exploratory laparotomy revealed large amount of intraluminal blood in second part of duodenum and a large pseudo aneurysm entering second part of duodenum that was ligated. Distal gastrectomy with duodenotomy with lysis of adhesions was done. LFTs trended down and jaundice resolved after procedure. Pseudoaneursym of IPDA is a rare complication of chronic pancreatitis. The mortality is 90-100% with acute hemorrhage in untreated patients and 12-50% even with aggressive treatment. Even though, most common presentation of pseuodaneusym is acute GI bleed, other presentations should not be overlooked. As shown in this case, our patient presented with obstructive jaundice. Direct pressure over the pancreaticobiliary ducts can cause recurrent pancreatitis and jaundice. Mesenteric angiography is the gold standard diagnostic test. Treatment options include angiographic embolization and surgical treatment. Early multidisciplinary approach with diagnostic and therapeutic interventions is needed to improve the outcome and decrease mortality.Figure: CT abdomen with contrast: Pseudoaneursym of inferior pancreaticoduodenal artery (arrow).Figure: Mesenteric Angiography:Pseudoaneursym of inferior pancreaticoduodenal artery(arrow).

Acute cholangitis: current concepts

Acute cholangitis, also known as ascending cholangitis, is a life-threatening systemic condition that results from a biliary tree infection and obstruction. Severe acute cholangitis was reported to have a mortality rate between 11 and 27% in the 1990s. This article is a literature review about acute cholangitis. Its aim is to review the latest literature about acute cholangitis and to discuss its pathogenesis, clinical presentation, diagnosis, prognosis, risk factors and treatment. Ovid Medline and PubMed database searches were performed for articles about acute cholangitis published in English from 1877 to 2016. The keyword search headings included 'acute', 'ascending' and 'cholangitis', and a combination of these were used. Only articles with full-text descriptions were chosen for this literature review. Common causes of biliary tree obstruction include choledocholithiasis, benign and malignant biliary strictures. According to the Tokyo Guidelines, clinical presentation, laboratory blood results and diagnostic imaging are important in the diagnosis of acute cholangitis. Treatments consist of intravenous fluids and antibiotics followed by biliary decompression and drainage. Available drainage options include endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, endoscopic ultrasound and open surgical drainage. It is important to diagnose acute cholangitis as early as possible to initiate appropriate treatments to reduce mortality and morbidity.

Unusual presentation of a distal cholangiocarcinoma

We report a case of a 51-year-old male presented with abdominal pain and itching, whereas jaundice occurred afterwards. Diagnosis was made by means of CT and better assessed by MRI and endoscopic ultrasounds. Patient was treated with an open Whipple's procedure, and after an 18-month follow-up he was doing well.