Cases reported "Cholestasis"

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1/14. Percutaneous bowel drainage for jaundice due to afferent loop obstruction following pancreatoduodenectomy: report of a case.

    A case of jaundice due to an obstruction of the afferent loop following a pancreatoduodenectomy is presented. The dilated loop of the jejunum was drained percutaneously with a 12-F gastrostomy tube. Localized peritonitis around the puncture site was managed conservatively and the obstructive jaundice improved. The treatment strategy for this type of jaundice is discussed.
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2/14. Obstructive biliary symptomatology as the first sign of HIV-infection.

    A 41-year-old white homosexual man presented with epigastric pain and jaundice. physical examination showed enlargement of bilateral axillar and left inguinal lymph node, while ERCP and a CT scan suggested interruption of bile flow in the intrapancreatic tract of the common bile duct. An endoprosthesis was positioned in the common bile duct during the ERCP. blood tests (both ELISA and Western blot techniques) showed positivity for anti-hiv antibodies and a CD4 count of 780/mmc (normal: 900-1,200/mmc). A few days later, a dramatic increase of the size of a lymph node in this right axilla occurred, rapidly reaching 5 cm of diameter. A biopsy was performed at this level, and histological examination revealed a high grade B-cell Burkitt type lymphoma. bone marrow biopsy was negative, as well as lumbar puncture. Aggressive chemotherapy with adriamycin, cyclophosphamide, bleomycine, eldesine and prednisone, together with intratechal administration of methotrexate, was attempted. However, after a marginal and transient regression, the NHL rapidly progressed and the patient eventually died seven months after the diagnosis of NHL. A post mortem examination confirmed the diagnosis of burkitt lymphoma of the peripancreatic and axillar lymph nodes, with diffusion to the leptomeninges, subaracnoideal spaces and encephalus. No signs of lymphoma were detected in other nodal or extra nodal areas.
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3/14. Performing percutaneous transphepatic cholangiography using simple x-ray equipment.

    Percutaneous transhepatic cholangiography (PTC) is a valuable procedure used for diagnosing diseases of bile duct. It is simple to perform, safe, and inexpensive. The only equipment needed to perform PTC is a simple x-ray machine and puncture needle 14 cm long and of 0.1 cm core diameter. As long as the puncture point is selected accurately and operation is performed correctly, an excellent image can be achieved. This procedure can therefore be used in developing countries where expensive, modern technology is not available. We report a case of a 50 year old female patient in whom the procedure was successfully used.
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4/14. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.

    Endoscopic biliary stenting is the most common method of treating obstructive jaundice. We present a new technique of biliary drainage using endoscopic ultrasound (EUS) and EUS-guided puncture of the common bile duct (CBD). A 56-year-old man with obstructive jaundice was referred for EUS and endoscopic retrograde cholangiopancreatography (ERCP) because a computed tomography (CT) scan had shown a pancreatic mass in the head of the pancreas and a dilated CBD. The patient was enrolled in a preoperative chemoradiotherapy protocol and biliary stenting was required. Deep cannulation was not obtained even after a precut and the procedure was stopped. Using a therapeutic EUS scope (FG 38X Pentax), the CBD was punctured with a 5-F needle-knife under EUS guidance and a cholangiogram was obtained. A 0.35-inch guide wire was introduced into the CBD. The EUS scope was removed and a duodenoscope was introduced, allowing the placement through the duodenum of a 10-F plastic stent. The CBD was drained properly. No complication occurred.
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5/14. Percutaneous transhepatic endobiliary drainage of hepatic hydatid cyst with rupture into the biliary system: an unusual route for drainage.

    The most common and serious complication of hydatid cyst of the liver is rupture into the biliary tract causing obstructive jaundice, cholangitis and abscess. The traditional treatment of biliary-cystic fistula is surgery and recently endoscopic sphincterotomy. We report a case of complex heterogeneous cyst rupture into the biliary tract causing biliary obstruction in which the obstruction and cyst were treated successfully by percutaneous transhepatic endobiliary drainage. Our case is the second report of percutaneous transbiliary internal drainage of hydatid cyst with rupture into the biliary duct in which the puncture and drainage were not performed through the cyst cavity.
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6/14. Endoscopic therapy in the management of hepatobiliary hydatid disease.

    Hydatid disease constitutes a serious public health problem throughout the world, especially in endemic areas, despite the use of various kinds of preventive measures. Currently, there are three treatment options for hepatic hydatid disease including surgery, PAIR (puncture, aspiration, injection, and re-aspiration), and chemotherapy with benzimidazole compounds. Each of these therapeutic modalities has limitations depending on the individual case. The authors review the use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary hydatid disease (HHD) to clarify its place in the treatment algorithm among surgical, medical, and percutaneous measures. ERCP in the preoperative period: (1) defines the cystobiliary relationship to help in surgery planning, (2) permits evaluation for acute conditions like cholangitis and obstruction so that subsequent surgery can be performed on an elective basis, (3) may give permanent cure specifically in cases of frank intrabiliary rupture if evacuation of biliary tract and cystic cavity is manageable, and (4) when combined with preoperative endoscopic sphincterotomy may decrease the incidence of the development of postoperative external fistula. ERCP in the postoperative period: (1) can help to clarify the causes of ongoing or recurrent symptoms or laboratory abnormalities, (2) may help to resolve the obstruction or cholangitis due to residual material in biliary ducts, (3) may provide the chance to manage postoperative external biliary fistulae, and (4) may be a realistic solution for secondary biliary strictures. Considering the current literature and adding this experience, the authors propose a new treatment algorithm in HHD including medical, surgical, PAIR, and ERCP-related therapies. To illustrate the algorithm, a case is presented of a patient who had a persistent external biliary fistula in the postoperative period and was managed successfully by endoscopic approach.
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7/14. Magnetic resonance-guided biliary drainage in a patient with malignant obstructive jaundice and thrombocytopenia.

    In a patient suffering from malignant obstructive jaundice and thrombocytopenia, magnetic resonance imaging (MRI) was used to guide percutaneous transhepatic biliary drainage, to avoid blind puncture of the bile ducts using fluoroscopy. The first puncture approach was successful, and an MRI-visible guide wire and drainage catheter were inserted successfully within 35 min. The course after the intervention was uneventful, and the patient's fever and itching improved. MRI guidance facilitated optimal procedure planning and high puncture accuracy.
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8/14. Hepaticogastrostomy by echo-endoscopy as a palliative treatment in a patient with metastatic biliary obstruction.

    A palliative hepaticogastrostomy was performed under endoscopic ultrasound guidance in a patient with inoperable hepatic hilar obstruction, creating an anastomosis between the dilated left hepatic duct and the stomach, to relieve symptoms of cholangitis and to allow biliary drainage. This therapeutic procedure was used as an alternative method of drainage of the biliary tree because endoscopic retrograde cholangiopancreatography was not possible and because the percutaneous metallic stent which had been inserted earlier had become occluded (probably by tumor overgrowth). It was a two-step procedure. In the first step a hepatic duct was punctured through the gastric wall with placement of a plastic stent, which created a fistula between them. In a second step a covered, metallic, self-expandable stent was substituted for the plastic stent to maintain the anastomosis and to improve patency over the medium term. The patient's fever was relieved and the bilirubin level fell; the patient remained asymptomatic at the five-months-follow-up.
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9/14. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases.

    BACKGROUND: Only a few cases have been reported of EUS-guided drainage of obstructed pancreatic or bile ducts. An initial experience with EUS-guided rendezvous drainage after unsuccessful ERCP is reported. methods: EUS-guided transgastric or transduodenal needle puncture and guidewire placement through obstructed pancreatic (n=4) or bile (n=2) ducts was attempted in 6 patients. Efforts were made to advance the guidewire antegrade across the papilla or surgical anastomosis. If guidewire passage was successful, rendezvous ERCP with stent placement was performed immediately afterward. RESULTS: EUS-guided duct access and intraductal guidewire placement was accomplished in 5 of 6 cases, with successful traversal of the obstruction, and rendezvous ERCP, with stent placement in 3 of 6 cases (two biliary, one pancreatic). The procedure was clinically effective in all successful cases (two patients with malignant obstructive jaundice, one with relapsing pancreatitis after pancreaticoduodenectomy). There was one minor complication (transient fever) but no pancreatitis or duct leak after successful or unsuccessful procedures. CONCLUSIONS: EUS is a feasible technique for allowing rendezvous drainage of obstructed biliary or pancreatic ducts through native papillae or anastomoses after initially unsuccessful ERCP.
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10/14. EUS-guided transhepatic cholangiography: report of 6 cases.

    BACKGROUND: This report describes a novel application of EUS-guided cholangiography in which a transhepatic approach was used to alleviate perihilar and distal biliary obstructions when this could not be accomplished at ERCP. methods: EUS-guided transhepatic cholangiography was used to alleviate symptoms of biliary obstruction in 6 patients. In 4 cases, after transgastric puncture of an intrahepatic branch of the obstructed bile duct with a 19- or a 22-gauge EUS needle, a guidewire was advanced antegrade across both the biliary stricture and the papilla. Subsequently, a rendezvous procedure was performed, allowing ERCP and stent placement. OBSERVATIONS: EUS-guided transhepatic cholangiography was performed in 6 patients, with successful rendezvous ERCP and stent placement in 4, and transduodenal stent placement in another patient. Stent placement was unsuccessful in one patient, because of the inability to advance a guidewire into the common hepatic duct. There was no immediate complication of the procedures. CONCLUSIONS: EUS-guided transhepatic cholangiography can be used to access and to drain bile ducts that are obstructed by proximal, as well as distal lesions when ERCP is unsuccessful.
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