Search

Yield of Repeat ERCP for Persistently Elevated LFTs After a Previously Normal Cholangiogram in Liver Transplant Patients with Choledochocholedochostomy Anastomosis Evan L. Fogel, Lee McHenry Jr., James L. Watkins, Suzette Schmidt, A. J. Tector, Jonathan A. Fridell, Stuart Sherman, Glen A. Lehman Background: Biliary tract complications occur in 20-30% of patients after orthotopic liver transplantation (OLT), with bile leaks and anastomotic strictures most often identified. ERCP is generally the preferredmethod of evaluation, and is usually performed for persistently elevated or rising LFTs post-OLT. A normal ERC suggests an alternative explanation for the abnormal LFTs (eg. rejection). However, exclusion of other causes may prompt a repeat ERCP. This study examines the yield of a 2nd ERCP, performed after a previously normal exam, in the evaluation of persistently abnormal or rising LFTs. Methods: From 1/99-10/ 03, patients who had a previously normal post-OLT ERC (with or without prior endoscopic intervention) and underwent repeat evaluation for the above indications were identified from our ERCP database. The biliary anastomosis had been established by choledochocholedochostomy in all patients. Complications were graded according to consensus criteria. Results: Overall, 34 patients (who underwent 46 follow-up ERCPs) were identified, 31 of which had biliary continuity established without a T-tube. Twenty-seven ERCPs were performed in 22 patients who had no prior therapy (Group 1), while 19 ERCPs were performed in 12 patients who had prior intervention but had subsequently normalized their cholangiograms (Group 2). Themean interval between the initial normal ERCand the follow-up study was 5.5 months (range 0.5-24.0) in Group 1 and 5.3 months (range 0.3-29) in Group 2. The findings at the 2nd ERC are as noted in the Table. In both groups, 63% of patients had a persistently normal study, while 37% had new pathology identified. Two patients developed pancreatitis (4.3%; 1 mild, 1 moderate) and one patient had a mild post-sphincterotomy bleed (overall complication rate 6.5%). Summary: In over one-third of patients with a previously-normal post-OLT ERC, new findings (strictures, most often) were identified at repeat ERC performed for persistently elevated or rising LFTs. Conclusion: Repeat ERC can identify the cause of persistently abnormal LFTs in a subset of OLT patients despite a previously normal ERC, and should be considered when an alternative explanation is not identified.

A patient hospitalized with the clinical diagnosis of acute cholecystitis had a normal cholangiogram and recovered without medical or surgical intervention. During the same week, two adults in an acquainted family had a similar syndrome at home. Echovirus 11 was cultured from the stool of all three patients, as well as from four other members of the same two families who had concurrent diarrheal illness. Serologic evidence confirmed acute echovirus 11 infection in the hospitalized patient. In the absence of evidence of a communitywide epidemic of cholecystitis, the coexistence of viral infection with biliary tract symptoms could represent an ongoing endemic situation. Recognition of this syndrome could make it possible to avoid unnecessary major surgical procedures.

Background: This retrospective study evaluated the use of diagnostic and therapeutic ERCP in pre- and postoperative patients with hepatic hydatid disease. Methods: For 8 years, ERCP was performed in 39 patients with hepatic echinococcal disease. Indications in the preoperative group of patients (n = 19) included a cholestatic enzyme profile in all cases; jaundice or acute cholangitis also was present in, respectively, 14 and 7 cases. In the postoperative group (n = 20), indications for ERCP included persistent external biliary fistula after surgery in 10 patients, jaundice in 8, acute cholangitis in 7, and right upper quadrant pain in 2 patients. Results: ERCP findings in the preoperative group included cystobiliary fistula (9 patients), external compression of the hepatic biliary system (5), hydatid vesicles and/or membranes within the biliary tract (3), intrahepatic duct stricture (1), and a normal cholangiogram (4). The most common ERCP finding in the postoperative group was external biliary fistula (10 patients); other findings consisted of hydatid cyst material within the bile duct (4), bile duct stenosis (2), cystobiliary fistula and hydatid cyst material in the bile duct (1), cystobiliary fistula (1), hydatid membranes in the gallbladder (1), extrinsic compression to bile ducts (1), and a normal cholangiogram (1). In the preoperative group, endoscopic sphincterotomy was performed in 11 patients, with balloon catheter extraction in 2; complete resolution of findings was achieved in 10 cases. In the postoperative group, sphincterotomy (with balloon or basket extraction as needed) was performed in 19 patients, stents were placed in 2 patients, 1 patient underwent balloon dilatation, and 1 had nasobiliary drainage; there was complete resolution of the findings in 14 of the 20 patients. Conclusions: ERCP and related therapeutic maneuvers are safe and valuable in the pre- and postoperative management of patients with hepatic hydatid disease.

Postoperative biliary complications following extensive hepatic resections are complex, often requiring a multidisciplinary team approach. We describe a case of a free bile duct leak following extended right hepatectomy and surgical hepaticojejunostomy treated with percutaneous transhepatic hepaticojejunostomy in which a radiofrequency guidewire was used to gain enteral access. A modified internal/external biliary catheter was left in place. The patient was enrolled in a benign biliary stricture protocol, and 8 months later, the catheter was removed following a normal cholangiogram and biliary manometric perfusion testing. At 3-month follow-up after catheter removal, the patient is asymptomatic with no clinical, biochemical, or radiographic evidence of biliary leak or obstruction.

Introduction: Percutaneous nephrolithotomy is generally considered a safe option for the management of large complex or infectious upper urinary tract calculi. Biliary tract injury is a rare and potentially serious complication of percutaneous nephrolithotomy that can even lead to mortality, especially in cases where biliary peritonitis develops. All reported cases of biliary tract injury have been managed by either open or laparoscopic cholecystectomy. Case Presentation: Herein for the first time, we report a 39-year old woman with biliary tract injury following percutaneous nephrolithotomy who was managed less invasively by insertion of a percutaneous cholecystostomy tube. The patient was discharged home shortly thereafter, and the tube was later removed at a follow up visit after a normal cholangiogram. Conclusions: Biliary tract injury is a rare and potentially serious complication of percutaneous nephrolithotomy that can even lead to mortality. If a biliary tract injury is suspected during percutaneous renal procedures, diverting the bile away from the leak may resolve the problem without the need for a cholecystectomy. Ideally this can be done with ERCP and a stent, but in cases where this is not technically feasible; a percutaneous cholecystostomy can be successful at accomplishing the same result.

Spontaneous perforation of the biliary tract is rare in infants & children with less than 100 cases reported in English Literature till date. We report two cases of this rare clinical entity in a 9-month-old boy and other of a 2-year old boy. Both patients presented with clinical features of acute peritonitis. Laparotomy revealed sterile biliary peritonitis with a normal cholangiogram in the infant and biliary perforation in other child. Simple drainage in the former and cholecystostomy with external biliary drainage in later resulted in a satisfactory outcome.

ERCP is the gold standard for pancreaticobiliary evaluation but is associated with complications. Less invasive diagnostic alternatives with similar capabilities may be cost-effective, particularly in situations involving low prevalence of disease. The aim of this study was to compare the performance of endoscopic ultrasound (EUS) with magnetic resonance cholangiopancreatography (MRCP) and ERCP in the same patients with suspected extrahepatic biliary disease. The economic outcomes of EUS-, MRCP-, and ERCP-based diagnostic strategies were evaluated.Prospective cohort study of patients referred for ERCP with suspected biliary disease. MRCP and EUS were performed within 24 h before ERCP. The investigators were blinded to the results of the alternative imaging studies. A cost-utility analysis was performed for initial ERCP, MRCP, and EUS strategies for these patients.A total of 30 patients were studied. ERCP cholangiogram failed in one patient, and another patient did not complete MRCP because of claustrophobia. The final diagnoses (N = 28) were CBD stone (mean = 4 mm; range = 3-6 mm) in five patients; biliary stricture in three patients, and normal biliary tree in 20. Two patients had pancreatitis after therapeutic ERCP, one after precut sphincterotomy followed by a normal cholangiogram. EUS was more sensitive than MRCP in the detection of choledocolithiasis (80% vs 40%), with similar specificity. MRCP had a poor specificity and positive predictive value for the diagnosis of biliary stricture (76%/25%) compared to EUS (100%/100%), with similar sensitivity. The overall accuracy of MRCP for any abnormality was 61% (95% CI = 0.41-0.78) compared to 89% (CI = 0.72-0.98) for EUS. Among those patients with a normal biliary tree, the proportion correctly identified with each test was 95% for EUS and 65% for MRCP (p0.02). The cost for each strategy per patient evaluated was $1346 for ERCP, $1111 for EUS, and $1145 for MRCP.In this patient population with a low disease prevalence, EUS was superior to MRCP for choledocholithiasis. EUS was most useful for confirming a normal biliary tree and should be considered a low-risk alternative to ERCP. Although MRCP had the lowest procedural reimbursement, the initial EUS strategy had the greatest cost-utility by avoiding unnecessary ERCP examinations.

The clinical and pathological findings of idiopathic ductopenia were studied in a 30-year-old woman who initially manifested jaundice and pruritus. Serum biochemical tests of liver function indicated severe and progressive cholestasis. Viral hepatitis markers and circulating autoantibodies were absent. The patient had a normal cholangiogram and lacked evidence of inflammatory bowel disease. Histological examination of a liver specimen showed severe cholestasis and absence of interlobular bile ducts. Severe jaundice and intractable pruritus developed in the patient and served as the indications for liver transplantation 4 months after initial examination. Transplantation resulted in prompt and complete resolution of the jaundice and pruritus. Two types of idiopathic adulthood ductopenia associated with different prognoses are recognized. Patients with type 1 idiopathic adulthood ductopenia are asymptomatic or manifest symptoms of cholestatic liver disease. They tend to have less destruction of the intrahepatic bile ducts on liver biopsy specimens. Their clinical course ranges from spontaneous improvement to progression to biliary cirrhosis. In contrast, patients with type 2 idiopathic adulthood ductopenia generally manifest initial symptoms of decompensated biliary cirrhosis, have extensive destruction of the intrahepatic bile ducts on liver biopsy, and frequently require orthotopic liver transplantation.

Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential tool to investigate patients with the postcholecystectomy syndrome. A normal cholangiogram usually rules out the presence of biliary tract disease, and further investigations are directed towards other organ systems. We present a case in which a normal ERCP caused a significant delay in reassessing the biliary tree in a patient who eventually presented with choledocholithiasis. A repeat ERCP should be considered in patients with persistent biliary tract pain, even if the initial ERCP shows no abnormality.

The diameter of extrahepatic and intrahepatic bile ducts was measured on 50 normal retrograde cholangiograms and on the cholangiograms of 109 post-cholecystectomy patients undergoing endoscopic retrograde cholangiopancreatography: 70 of the post-cholecystectomy patients had a normal cholangiogram and 39 had retained stone or biliary stricture, of whom 17 were jaundiced. Biliary diameter at all points measured was greater in the post-cholecystectomy patients with no biliary lesion than in normals, and further increased in the presence of pathology (e.g. retained stone). The extent of overlap in biliary diameter between all these three groups is so great that measurement of bile duct calibre cannot separate patients with retained stone from post-cholecystectomy patients without retained stone, or from patients with an entirely normal biliary tree, even in the presence of obstructive jaundice. Methods of evaluating the biliary tract which rely on the measurement of bile duct diameter (e.g. ultrasound) are therefore of limited value in the investigation of post-cholecystectomy patients.

Percutaneous transhepatic cholangiography has been attempted in 104 patients with jaundice due to a variety of causes. Biliary tract visualization was accomplished in 57, the majority having extrahepatic obstruction due to malignancy or calculi. Nonvisualization (a "negative" study) or a normal cholangiogram, was commonly associated with parenchymal liver disease which was confirmed by percutaneous needle liver biopsy. With an injection technique and television roentgen monitoring, false negative studies have been eliminated in patients with dilated intrahepatic bile ducts, and even normal ducts can be visualized. Needle liver biopsy has become an alternative to unproductive biliary tract exploration.