1/38. Peroral jejunoscopy for treating stenosis of hepaticojejunostomy after pancreatoduodenectomy.A 72-year-old woman suffered from relapsing cholangitis after pylorus-preserving pancreatoduodenectomy for chronic pancreatitis. The common hepatic duct had been anastomosed to the jejunum 8 cm distal to the duodenojejunostomy. Peroral jejunoscopy showed a severe stenosis of the hepaticojejunostomy, which was endoscopically enlarged by means of electroincision and balloon dilation, subsequently. No procedure-related complications occurred. The patient has been asymptomatic for 34 months. Most of the strictures of bilioenterostomy are reportedly treated by surgical revision, the percutaneous transhepatic approach, or the percutaneous transjejunal approach. Endoscopic treatment may be attempted in cases in which the postoperative anatomy potentially allows endoscopic access, because of its minimal invasiveness and effectiveness.- - - - - - - - - - ranking = 1keywords = cholangitis (Clic here for more details about this article) |
2/38. Extrahepatic biliary stenoses after hepatic arterial infusion (HAI) of floxuridine (FUdR) for liver metastases from colorectal cancer.Hepatic arterial infusion of floxuridine is an effective treatment for unresectable hepatic metastases from colorectal cancer. Despite its pharmacological advantage of higher tumor drug concentration with minimal systemic toxicity, hepatic arterial infusion of floxuridine is characterized by regional toxicity, including hepatobiliary damage resembling idiopathic sclerosing cholangitis (5-29% of treated cases). Unlike previous reports describing biliary damage of both intrahepatic and extrahepatic ducts, a case series of extrahepatic biliary stenosis after hepatic arterial infusion with floxuridine is herein described. Between September 1993 and February 1999, 54 patients received intraarterial hepatic chemotherapy based on continuous infusion of floxuridine (dose escalation 0.15-0.30 mg/kg/day for 14 days every 28 days) plus dexamethasone 28 mg. Twenty-seven patients underwent laparotomy to implant the catheter into the hepatic artery, the other 27 patients receiving a percutaneous catheter into the hepatic artery through a transaxillary access. Five patients (9.2%) developed biliary toxicity with jaundice and cholangitis (3 cases), alterations of liver function tests and radiological features of biliary tract abnormalities. They received from 9 to 19 cycles (mean 14.5 /- 6.3 cycles) of floxuridine infusion with a total drug delivered dose ranging from 20.3 to 41.02 mg/kg (mean: 31.4 /- 13.5 mg/kg). Extrahepatic biliary sclerosis was discovered by computed tomography scan and ultrasound, followed by endoscopic retrograde cholangiopancreatography and/or percutaneous cholangiography in 3 cases. Radiological findings included common hepatic duct complete obstruction in 1 case, common hepatic duct stenosis in 2 cases, common bile duct obstruction in 1 case, and intrahepatic bile ducts dilation without a well-recognized obstruction in 1 case. Two patients were treated by sequentially percutaneous biliary drainage and balloon dilation while 1 patient had an endoscopic transpapillary biliary prosthesis placed. Percutaneous or endoscopic procedures obtained the improvement of hepatic function and cholestatic indexes without subsequent jaundice or cholangitis. In two patients suppression of floxuridine infusion allowed the improvement of hepatic function. The present series suggests that in some patients receiving hepatic arterial infusion of floxuridine extrahepatic biliary stenosis may represent the primary event leading to a secondary intrahepatic biliary damage that does not correlate with specific floxuridine toxicity but results from bile stasis and infection, recurrent cholangitis and eventually biliary sclerosis. Aggressive research for extrahepatic biliary sclerosis is advised, since an early nonsurgical treatment of extrahepatic biliary stenosis may prevent an irreversible intrahepatic biliary sclerosis worsening the prognosis of metastatic liver disease.- - - - - - - - - - ranking = 4keywords = cholangitis (Clic here for more details about this article) |
3/38. Cholangiojejunal fistula caused by bile duct stricture after intraoperative injury to the common hepatic artery.A 68-year-old man, admitted for the treatment of recurrent cholangitis after a pancreatoduodenectomy (PD) performed 3 years previously was diagnosed as having multiple hepaticolithiasis. On laparotomy, the hepatic artery was not recognized. The anastomosed common hepatic duct was obstructed, and a fistula had been formed between the right hepatic duct and the Roux limb of the jejunum. lithotripsy was performed from this fistula and it was reanastomosed. Angiography was performed postoperatively and it revealed common hepatic artery injury, most likely to have occurred during the previous PD. The patient's postoperative course was uneventful and he has been asymptomatic for 8 months after the operation, indicating that reanastomosis of the fistula can be an effective method. The stricture of the anastomosis was suspected to be mainly due to cholangial ischemia, because no episode of anastomotic leak or retrograde biliary infection had occurred during the PD perioperative period. There are several reports of late stricture of anastomosis 5 or more years after cholangiojejunostomy. This patient, therefore, requires further long-term follow up.- - - - - - - - - - ranking = 1keywords = cholangitis (Clic here for more details about this article) |
4/38. common bile duct compression by an abdominal aortic aneurysm: an unusual cause of biliary tract dilatation.Extra-hepatic bile duct compression is encountered commonly among patients with pancreatic disease, primary sclerosing cholangitis, and cholangiocarcinoma. However, in an elderly lady with predominantly cholestatic liver test abnormalities, magnetic resonance cholangiopancreatography (MRCP) demonstrated a large abdominal aortic aneurysm that was causing extra-hepatic bile duct compression and concomitant proximal bile duct dilatation. This unusual and uncommon finding was almost certainly the explanation for her liver test dysfunction. This report draws attention to the increasing role for MRCP as an accurate, but non-invasive means of appraisal of the pancreatico-biliary tree. In addition, an unusual and uncommon cause of extra-hepatic bile duct compression is discussed.- - - - - - - - - - ranking = 1keywords = cholangitis (Clic here for more details about this article) |
5/38. Follicular cholangitis: another cause of benign biliary stricture.The case of a 57-year-old woman with a benign biliary stricture is described. Radiological examinations showed granularly elevated lesions in the common hepatic duct and severe stenosis at the hepatic hilum. Under a tentative diagnosis of hepatic hilar bile duct cancer, the patient underwent extended right hepatectomy with bile duct resection. However, pathological and immunohistochemical studies revealed a benign stricture with remarkable formation of lymph follicles with germinal centers, which could be termed "follicular cholangitis". This is the first case report of this uncommon presentation of inflammatory changes of the bile duct. Its etiology was unknown, and more investigation is encouraged to clarify its relationship to systemic disorders and malignancies. As difficulty remains in discriminating between benign and malignant strictures by nonsurgical modalities at present, surgical resection without complications provides a feasible approach to such a benign lesion.- - - - - - - - - - ranking = 5keywords = cholangitis (Clic here for more details about this article) |
6/38. biliary tract invasion and obstruction by hepatocellular carcinoma: report of five cases.Major biliary tract obstruction caused by tumour invasion is a rare manifestation of hepatocellular carcinoma. The authors had the opportunity to diagnose and treat five such cases, three of whom had features of acute cholangitis. The prevalence of both hepatocellular carcinoma and recurrent pyogenic cholangitis is high in patients from the far east. The former may first present under the guise of the latter. Gastroenterologists and surgeons should be aware of hepatocellular carcinoma when managing these patients who present with obstructive jaundice, gross hepatomegaly and cholangitis.- - - - - - - - - - ranking = 3keywords = cholangitis (Clic here for more details about this article) |
7/38. Early recurrence of obstructive jaundice after placement of a self-expanding metal endoprosthesis.Self-expanding metal endoprostheses have ben used in the treatment of malignant obstructive jaundice for a few years. We report on a patient with obstructive jaundice due to a metastasis of a squamous cell lung cancer into the pancreatic head who received an expandable metal endoprosthesis and suffered recurrent jaundice and cholangitis after 38 days. On repeat ERCP, a very narrow stenosis was seen in the stent lumen caused by tumor ingrowth through the mesh. Intraluminal biopsies showed squamous cell carcinoma. A 10 Fr plastic endoprosthesis was inserted through the self-expanding stent with good drainage. On the basis of this experience, we feel that when faced with a patient with obstructive jaundice due to metastatic disease from a rapidly progressive carcinoma, the use of the currently available self-expanding metal endoprosthesis should be discouraged until the results of prospective studies with large numbers of patients have proven its superiority over the plastic endoprostheses. Meanwhile, modifications to prevent tumor ingrowth through the mesh of the stent are under investigation.- - - - - - - - - - ranking = 1keywords = cholangitis (Clic here for more details about this article) |
8/38. fasciola hepatica infestation as a very rare cause of extrahepatic cholestasis.fasciola hepatica, an endemic parasite in turkey, is still a very rare cause of cholestasis worldwide. Through ingestion of contaminated water plants like watercress, humans can become the definitive host of this parasite. Cholestatic symptoms may be sudden but in some cases they may be preceded by a long period of fever, eosinophilia and vague gastrointestinal symptoms. We report a woman with cholangitis symptoms of sudden onset which was proved to be due to fasciola hepatica infestation by an endoscopic retrograde cholangiography.- - - - - - - - - - ranking = 1keywords = cholangitis (Clic here for more details about this article) |
9/38. common bile duct obstruction caused by the hydatid daughter cysts.echinococcosis is a human parasitary disease. In 2002, 29 new cases of liver echinococcosis were recorded in croatia. Liver is the most common site of hydatid cysts. Nine patients with echinoccocal liver disease were operated in our department in 2002. Here we present a case where a patient with verified hydatid cyst in the left liver lobe developed high fever, jaundice, nausea, vomiting and pain in the upper abdomen. The symptoms were initially ascribed to the acute cholangitis. After unsuccessful antibiotic treatment, computerized tomography and endoscopic retrograde cholangiopancreatography (ERCP) were performed, demonstrating daughter cysts in the common bile duct. During ERCP, papilotomy was made and daughter cysts were extracted. Hydatid cyst was surgically removed, and a communication between the cyst and left hepatic duct was noted during surgery. Pericystectomy, choledochotomy, removal of remaining daughter cysts from the common bile duct, and sutures of left hepatic duct were performed. The patient recovered fully after the surgery. One of the possible complications of the liver hydatid cysts is the communication between cyst and the biliary tree. Such communications are usually asymptomatic, but symptoms can also mimic acute cholangitis and jaundice, which may lead to the misdiagnosis of the patient's condition.- - - - - - - - - - ranking = 2keywords = cholangitis (Clic here for more details about this article) |
10/38. Unresectable hilar cholangiocarcinoma completely reduced by external radiation therapy.A 68-year-old woman was referred to our hospital with liver dysfunction. Abdominal ultrasonography showed an isoechoic mass in the hepatic hilum. Abdominal computed tomography (CT) disclosed a homogenous mass adjacent to the portal bifurcation, and endoscopic retrograde choledocho-pancreatography (ERCP) revealed complete obstruction from the common hepatic duct to the hepatic duct confluence. After insertion of the endoscopic nasobiliary drainage (ENBD) tube, laparotomy was performed, revealing an approximately 5x6-cm elastic hard mass at the hepatic hilum, mainly spreading to the left hepatic duct, and involving surrounding vascular structures such as the portal vein and right and left hepatic arteries. Therefore, she was treated by external radiation therapy (ERT) of 60 Gy in 30 sessions after insertion of endoscopic retrograde biliary drainage (ERBD) tubes to bilateral hepatic ducts to replace the ENBD tube. After the completion of ERT, she was discharged from the hospital in good health. Three months later, she was readmitted for cholangitis and received antibiotic treatment. Surprisingly, abdominal CT disclosed complete remission of the tumor. ERCP revealed patency of the common hepatic duct and hepatic duct confluence. Therefore, the ERBD tubes were removed. Specimens from the hepatic duct confluence, and bilateral hepatic ducts showed no malignancy histologically. She is doing well without recurrence more than 4 years after surgery.- - - - - - - - - - ranking = 1keywords = cholangitis (Clic here for more details about this article) |
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