11/373. Previous cholecystectomy and choledochal sphincter spasm after morphine sedation. PURPOSE: To describe a patient with probable choledochal sphincter spasm after preoperative morphine, and to suggest a history of cholecystectomy as a predisposing factor. CLINICAL FEATURES: A 60 yr old man for femoral-popliteal artery bypass grafting developed right upper quadrant abdominal pain after preoperative morphine and scopolamine. He had a previous cholecystectomy. His pain was relieved with naloxone. CONCLUSION: Choledochal sphincter spasm should be part of a differential diagnosis in right upper quadrant pain after sedative doses of morphine, especially if there is a previous cholecystectomy. ( info) |
12/373. cholecystostomy: an unusual approach to stenting of a distal common bile duct stricture. Strictures, both benign and malignant, of the distal common bile duct (CBD) are reasonably common, and if stented are usually approached endoscopically via the duodenum, or transhepatically via an intrahepatic and then common hepatic duct. We describe a case of endoscopic stenting of a distal CBD stricture over a wire passed percutaneously through the gallbladder, cystic duct and into the duodenum. To our knowledge, this has not been previously described. ( info) |
| Biliary-type pain from sphincter of oddi dysfunction is not uncommon after cholecystectomy. An increased basal pressure of sphincter of Oddi manometry establishes the diagnosis and treatment is usually by endoscopic sphincterotomy. Both procedures carry a significant complication rate. A few patients with elevated sphincter pressure do not respond to therapy; the source of their pain may be elsewhere. This case report describes the use of intrasphincteric botulinum toxin injection for the diagnosis of sphincter of oddi dysfunction in a patient after repeated attempts at manometry had failed. This may provide a safe and easy method of determining whether sphincter of oddi dysfunction may be the cause of biliary pain in post/ cholecystectomy patients and help select patients who would benefit from subsequent sphincter ablation, without the risks of sphincter of Oddi manometry. prospective studies are first needed. ( info) |
14/373. Repair of common bile duct injury with the round and falciform ligament after clip necrosis: case report. Occasionally, as abdominal surgeons, we are confronted with common bile duct injury noted during video laparoscopic or open cholecystectomy. Usually this is solved by endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy and stent, or enteric bypass, suture repair and tube drainage. However, after such procedures, there is a significant number of patients with postoperative stenosis. Another alternative to repair common bile duct injury and correct postoperative stenosis is using the round and falciform ligament as circumferencial patch. Due to their closeness to the common bile duct and their adequate blood supply, they make a perfect autologous biological graft. ( info) |
| sphincter of oddi dysfunction is an underdiagnosed but important clinical condition. It should be considered in the differential diagnosis of biliary pain when the gallbladder sonogram shows no evidence of gallbladder disease. Hepatobiliary scanning (Tc-99m dimethyl iminodiacetic acid) may provide valuable information in the evaluation of these patients and may be helpful in monitoring response to treatment. ( info) |
16/373. Dilated bile duct in patients receiving narcotic substitution: an early report. Narcotic substitution is now widely used. morphine can induce a spasm of the sphincter of Oddi but dilation of bile duct has been reported only in an anecdotal case. In June 1995, we observed a first case of dilation of the common bile duct without organic obstacle in a hepatitis c virus (HCV)-infected patient who was under narcotic substitution, suggesting a causal relationship. We conducted a prospective study to evaluate the precise prevalence of bile duct abnormalities related to narcotic substitution in active intravenous drug or ex-intravenous drug users referred to our liver unit for histologic evaluation of HCV infection. We conducted a prospective study in a 30-month period of 334 HCV-infected patients, including 36 receiving narcotic substitution with methadone or buprenorphine. biliary tract was analyzed by ultrasonography and by endoscopy ultrasound in cases of bile duct abnormalities. Of the 36 patients under narcotic substitution, 3 (8.3%) had asymptomatic dilated bile duct without organic obstacle--defined as a common bile duct > or =9 mm--compared to 1 of 298 (0.03%; p < 0.001) of those who did not receive substitution. Narcotic substitution may lead to bile duct dilation that does not require invasive diagnosis procedures. ( info) |
17/373. Laparoscopic repair of cholecystoduodenal fistula: report of two cases. BACKGROUND: Laparoscopic surgery has become the standard of care for benign gallbladder disease. patients AND methods: We treated two middle-aged women having acute exacerbations of chronic gallbladder disease with laparoscopic cholecystectomy. A cholecystoduodenal fistula was diagnosed intraoperatively in each case. These fistulae were repaired laparoscopically using an endoscopic stapling device without complication. RESULTS: Each patient did well postoperatively and was discharged to home on the second postoperative day in good condition. CONCLUSIONS: Biliary-enteric fistula is a known complication of chronic gallbladder disease that is traditionally considered a contraindication to laparoscopic cholecystectomy. However, we believe laparoscopic repair to be a safe and effective approach in the hands of surgeons with significant laparoscopic experience. ( info) |
18/373. Vanishing bile duct syndrome in Hodgkin's disease: case report. CONTEXT: Liver damage is relatively common in patients affected by Hodgkin's disease. A smaller proportion of cases develops jaundice. Recently, the vanishing bile duct syndrome was described in Hodgkin's disease. The mechanisms of this severe complication have been poorly understood until now. OBJECTIVE: To describe a rare case of intra-hepatic cholestasis due to vanishing bile duct syndrome. DESIGN: Case report. CASE REPORT: A 38-year-old male patient affected by Hodgkin's disease. Liver biopsy showed no detectable Hodgkin's disease. Intra-hepatic cholestasis was found and none of the six portal tracts analyzed contained normal bile ducts. The treatment was based on conventional and high-dose escalation chemotherapy. The patient died from an irreversible liver failure while in complete remission from Hodgkin's disease. ( info) |
| The pathophysiology of choledochal cysts remains unclear, although an association with anomalous pancreato-biliary junction and the reflux of pancreatic enzymes into the biliary tree is known. Sphincter of Oddi (SO) manometry was performed in three patients with choledochal cysts. All patients exhibited an elevated basal pressure diagnostic of sphincter of oddi dysfunction. Two patients exhibited anomalous pancreato-biliary junction. This report suggests an association between the choledochal cyst and sphincter of oddi dysfunction, and may suggest that SO dysfunction plays a role in choledochal cyst formation. ( info) |
20/373. Duodenal tuberculosis with a choledocho-duodenal fistula. A 22-year-old man visited our hospital (National Cancer Center Hospital East) complaining of fatigue and anorexia. A laboratory investigation demonstrated a biochemical 'picture' of obstructive jaundice. An abdominal CT showed a low density mass in the retropancreatic area with multiple enlarged periportal lymph nodes. Upper gastrointestinal endoscopy revealed active ulceration on the dorsal wall of the descending part of the duodenum, and histopathology of the biopsy specimen revealed an ulcer with reactive inflammatory cell infiltration; no tumor cells were detected. The possibility of neoplasm had been ruled out by the use of CT and angiography. The jaundice recovered spontaneously and the abdominal mass gradually decreased in size. Endoscopic retrograde pancreatography showed no evidence of pancreatic disease; however, endoscopic retrograde cholangiography showed a choledocho-duodenal fistula. This patient showed hypersensitivity against the tuberculin skin test and mycobacterium tuberculosis was successfully detected in gastric juice by using a polymerase chain reaction method and culture. biopsy samples obtained from the duodenal ulcer at the second upper gastrointestinal endoscopy showed chronic inflammation with an epithelioid granuloma, suggesting tuberculosis. We thus diagnosed this case as a duodenal tuberculosis with a choledocho-duodenal fistula. To the best of our knowledge, there has been no report available of duodenal tuberculosis being the cause of a choledocho-duodenal fistula. ( info) |