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Simultaneous non-traumatic perforation of the extrahepatic bile duct and the gallbladder is an uncommon occurrence that has been infrequently reported. We describe a patient with a spontaneous perforation of both the extrahepatic bile duct and the gallbladder. A contrast-enhanced computed tomography (CECT) scan of the abdomen and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a perforation of the gallbladder and a free leak from the right hepatic duct, respectively. Endoscopic biliary drainage following a sphincterotomy and biliary stent placement led to a dramatic improvement in the patient's general condition. He was subsequently scheduled to undergo an elective cholecystectomy. Repeat ERCP performed at 4 weeks after the initial stenting showed a normal cholangiogram and a distally migrated stent, which was there after removed. However, early stent removal led to re-perforation of hepatic duct and gallbladder. A repeat endoscopic biliary drainage did not help, and the patient developed biliary peritonitis. Surgical exploration revealed a perforation at the fundus of the gallbladder, 400 ml of biliopurulent collection and a frozen Calot's triangle. A subtotal cholecystectomy, gall stone removal, and a thorough peritoneal lavage were undertaken. The patient improved postoperatively. The second biliary stent was removed after 4 months. This case report highlights the role of endoscopic biliary drainage in the management of an extrahepatic bile duct perforation and warns against the early removal of a biliary stent. [ABSTRACT FROM AUTHOR]

Jejunal access loop is fashioned in patients who undergo Roux en Y hepaticojejunostomy and biliary intervention is anticipated on follow up. Post-operative study of the biliary tree through the access loop is usually done under fluoroscopic guidance. We present a series of 20 access loop cholangiograms performed in our institution between August 2004 and November 2008. We aimed to evaluate the safety and efficacy of the procedure and to highlight the role of CT guidance in procuring access. Access loop was accessed using CT ( n = 13), ultrasound ( n = 3) or fluoroscopic guidance ( n = 4). Fluoroscopy was used for performing cholangiograms and interventions. Twelve studies had balloon plasty of the stricture at anastomotic site or high up in the hepatic ducts. Seven studies showed normal cholangiogram. Plasty was unsuccessful in one study. Technical success in accessing the jejunal access loop was 100%; in cannulation of anastomotic site and balloon plasty it was 95%. One case required two attempts. Procedure-related complications were not seen. All patients who underwent balloon plasty of the stricture were doing well for variable lengths of time. Access loop cholangiogram and interventions are safe and effective. CT guidance in locating/procuring the access loop is a good technique. [ABSTRACT FROM AUTHOR]

Background: Patients with cholestatic liver function tests and histological features of primary scleroslng cholangitis (PSC) but a normal cholangiogram are considered to have small duct PSC. The natural history of this condition is unknown. Methods: Thirty three patients with small duct PSC were identified among patients admitted for diagnostic workup of cholestatic liver function tests in one centre in the UK (Oxford) and one centre in Norway (Oslo). A total of 260 patients with large duct PSC were compared, and prognosis in terms of death, cholangiocarcinoma, biochemical features, histological features, and symptoms analysed. Results: Mean age at diagnosis was 38 years and 39 years in small duct and large duct PSC, respectively. Mean follow up was 106 months in small duct and 105 months in large duct patients. Four patients originally considered to have small duct developed large duct PSC. Two of these underwent liver transplantation during follow up. Of the remainder who did not develop large duct PSC, two patients died during follow up: one of liver failure and the other of cardiac death unrelated to her liver disease. A total of 122 (47%) large duct patients either required liver transplantation (34 patients) or died (88 patients). Small duct patients had a significantly better survival compared with large duct patients. Among small duct patients, none developed cholangiocarcinoma compared with 28 of 260 (11%) large duct patients. Conclusions: Patients with small duct PSC seem to have a good prognosis in terms of survival and development of cholangiocarcinoma. Small duct PSC progresses to large duct PSC in a small proportion of patients. [ABSTRACT FROM AUTHOR]

AbstractBackground and Aim: The role of endoscopic retrograde cholangiopancreatography (ERCP) is not yet fully established in children. The purpose of this study was to assess the use of ERCP in the diagnosis and management of various pancreaticobiliary disorders in children. Methods: Eighty-four ERCPs were performed over 5.5 years in 72 children with suspected pancreaticobiliary tract disorders with an adult-type duodenoscope. In all cases, indications, procedure time, ERCP findings, complications, patients course and therapeutic intervention (if any) were recorded. Results: The mean (± SD) age of these children was 8.8 ± 3.3 years. Successful cannulation was possible in 70 (97%) cases. Of the 44 cases with suspected biliary tract disease, 14 had a choledochal cyst, 13 had portal biliopathy, two each had CBD stones, primary sclerosing cholangitis and a bile leak, one had biliary ascariasis, eight had a normal cholangiogram, and CBD cannulation failed in two. Eight of the 28 children with suspected pancreatic disorders had chronic pancreatitis, five had pancreatic duct disruption, three had pancreas divisum and the rest had a normal pancreatogram (including all eight children with unexplained abdominal pain). Therapeutic ERCP was performed in 22 children, endoscopic nasobiliary or a nasocystic drain was placed in 16, biliary stenting was conducted in two, pancreatic duct stenting was conducted in three, and minor papilla dilation was conducted in one child. Six children had mild procedure-related complications. Conclusion: Endoscopic retrograde cholangiopancreatography is very useful in the treatment of cholangitis, bile leak, pseudocyst and pancreatic fistulae in children. However, its role in unexplained abdominal pain is doubtful. [ABSTRACT FROM AUTHOR]

Background/Aims Small duct primary sclerosing cholangitis is a rare clinical condition that may remain unrecognized. Diagnosis rests on clinical, biochemical, and histologic features consistent with primary sclerosing cholangitis but with normal cholangiogram findings. We report here a case of small duct primary sclerosing cholangitis in a patient who presented with jaundice. Methods Clinical Presentation. A 22-year-old Filipino gentleman with no known comorbids came in due to a 2-week history of jaundice with elevated transaminases, bilirubin and alkaline phosphatase. No other symptoms were noted. Hepatitis markers were all normal. Physical examination was unremarkable except for jaundice. Results Management. Magnetic resonance cholangiopancreatography was normal with no evidence of dilated intra- and extrahepatic ducts. Liver biopsy showed intrahepatic cholestasis with periductal fibrosis. Ursodeoxycholic acid was started which showed significant decrease in jaundice with improvement in biochemistries. Conclusions Recommendation. Small duct primary sclerosing cholangitis appears to have a more favorable prognosis than classic primary sclerosing cholangitis. However, further studies with long-term follow up are recommended to determine disease progression. [ABSTRACT FROM AUTHOR]

Purpose Two recent meta-analyses support operative CBD exploration (laparoscopic or open) as at least equal to ERCP for the management of choledocholithiasis with the gall bladder in situ. The literature regarding laparoscopic exploration is largely from enthusiasts and may not be transferable across institutions. In our institution both hepatobiliary and general surgeons perform cholecystectomy with variable comfort levels with laparoscopic CBD exploration. ERCP and laparoscopic antegrade transampullary biliary stents are available. We review the management of choledocholithiasis in this setting. Methods A retrospective review of all patients who underwent cholecystectomy during 2004 and 2005 at two Newcastle hospitals was conducted. Results The incidence of choledocholithiasis was 10.3% (70 patients). This was diagnosed pre-operatively in 36 patients; 22 underwent pre-operative ERCP (62.5% clearance) and 14 operative CBD exploration (100% clearance). An additional 22 patients with presumed choledocholithiasis had a normal cholangiogram at pre-operative ERCP. Operative cholangiogram first confirmed choledocholithiasis in 31 patients; CBD exploration was successful in 58.8% (10 of 17). Intra-operative biliary stents were inserted in 15 patients due to a small calibre CBD, failed exploration or lack of equipment and time for exploration. Hepatobiliary surgeons more frequently performed operative CBD exploration and stent placement. Conclusion The management of choledocholithiasis varies with the clinical scenario and local expertise. This series defines a role for intra-operative stent placement, suggests pre-operative ERCP is over-utilised, and that operative CBD exploration is successful with low morbidity. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]