Spontaneous common bile duct perforation due to choledocolithiasis accompanied with pancreaticobiliary maljunction in an adult: a case report

Background Spontaneous common bile duct (CBD) perforation is an extremely rare disease in adults. We report an adult case of CBD perforation due to choledocolithiasis accompanied with pancreaticobiliary maljunction, which is, to our knowledge, the first such case report based on a search using PubMed. Case presentation A 71-year-old woman with consciousness disorder was transported to the emergency department of another hospital. She was diagnosed as having severe peritonitis with septic shock and transferred to our hospital for emergency surgery. Enhanced computed tomography (CT) revealed supraduodenal CBD dilation similar to a diverticulum and a defect of bile duct wall continuity. Furthermore, CT showed a long common channel of the pancreaticobiliary duct, so she was diagnosed as having spontaneous CBD perforation with pancreaticobiliary maljunction. Emergency surgery was performed that revealed a necrotic diverticulum-like change on the supraduodenal part, and a 2.5 × 1 cm perforation was found on the anterolateral wall of the CBD. Peritoneal lavage was performed, and CBD perforation was resolved with a T-tube. The patient suffered refractory intra-abdominal and retroperitoneal abscess formation and bleeding from the abdominal wall, which required a long period of postoperative management. The T-tube was removed on day 136, and the patient was transferred on day 153. Conclusion The cause of CBD perforation is commonly considered to be increased intraductal pressure or weakness of the bile duct wall. In this case, pancreaticobiliary maljunction may have significantly influenced onset and the postoperative course. This case suggests that early surgical intervention and appropriate drainage are important to ensure survival.

Screening for Hilar Biliary Invasion in Ampullary Cancer Patients

Background: The treatment for ampullary cancer is pancreatoduodenectomy or local ampullectomy. However, effective methods for the preoperative investigation of hilar biliary invasion in ampullary cancer patients have not yet been identified. In this study, we aimed to determine an appropriate method for investigating hilar biliary invasion of ampullary cancer.Methods: Among 43 ampullary cancer patients, 34 underwent endoscopic treatment (n = 9) or surgery (n = 25). Imaging findings (thickening and enhancement of the bile duct wall on contrast-enhanced CT (CECT), irregularity on endoscopic retrograde cholangiography (ERC), thickening of the entire bile duct wall on intraductal ultrasonography (IDUS), and partial thickening of the bile duct wall on IDUS) and biliary biopsy results were compared with respect to their ability to diagnose hilar biliary invasion of ampullary cancer.Results: Hilar invasion was not observed in every patient. Among the patients who did not undergo biliary stent insertion, the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy showed the highest accuracy (100%) for diagnosing biliary invasion. However, each imaging finding and biliary biopsy yielded some false positive results.Conclusions: Although some false positive results were obtained with each method, the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy was useful for diagnosing hilar biliary invasion of ampullary cancer. However, hilar invasion of ampullary cancer is rare; therefore, the investigation of hilar biliary invasion of ampullary cancer might be unnecessary.Trial registration: not applicable

Bilious mask: parasite masquerading as malignant gall bladder polyp

A 31-year-old woman, presenting with right upper quadrant pain, was suspected to have malignant gall bladder polyp based on MRI and CT scan findings. She underwent radical cholecystectomy with excision of bile duct and hepaticojejunostomy. Surprisingly, histology revealed parasitic remnants within the bile duct wall with no evidence of malignancy. A year later, this young woman suffers significant impairment of quality of life, perhaps an aftermath to the radicality of the surgery. Our case demonstrates a masquerade of ‘malignant biliary polyp’ by a parasite. This raises the need for extensive investigations such as endoscopic ultrasound guided biopsies, parasitic serology and positron emission tomography (PET) scans when patients present with probable malignant biliary lesions, even in difficult-to-access areas. A preoperative diagnosis might have averted an unnecessary major surgery in this young woman.

Accuracy of brush cytology in biliopancreatic strictures: a single-center cohort study

Objective False positive and negative results are associated with biliary tract cell brushing cytology during endoscopic retrograde cholangiopancreatography (ERCP). The causes are uncertain. The purpose of this study was to evaluate the accuracy of diagnoses made via cell brushing in our center, and to explore the factors influencing diagnosis. Methods The clinical data of patients who underwent cell brushing at our center from January 2016 to August 2019 were retrospectively analyzed. These included age, gender, stricture location, thickness of the bile duct wall in the narrow segment, maximum diameter of the biliary duct above the stricture, number of cell brush smears, carbohydrate antigen 19-9, and carcinoembryonic antigen. Positive brush cytology results were compared with results of surgical histology or tumor biopsy as well as with the patient’s clinical course. Results Of the 48 patients who underwent cell brushing cytology, 27 (56.3%) had positive results. The sensitivity and specificity of biliary duct cell brushing was 79.4%, and 85.7%, respectively. None of the above-mentioned factors were associated with positive cytology brushing results. Conclusions Cell brushing cytology remains a reliable method for diagnosis of pancreaticobiliary malignancies.

Biliary Peritonitis Caused by Spontaneous Bile Duct Rupture in the Left Triangular Ligament of the Liver after Endoscopic Sphincterotomy for Choledocholithiasis

Spontaneous bile duct rupture is a rare condition in adults, with only 70 cases reported. Increased bile duct wall pressure may lead to rupture and biliary peritonitis. In this patient, the bile duct ruptured in the hepatic left triangular ligament. A 91-year-old man underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and endoscopic retrograde biliary drainage (ERBD) placement. One week later, removal of the ERBD and common bile duct stones and an endoscopic sphincterotomy (EST) were performed. Four days later, the patient had abdominal pain, increased inflammatory reaction, and jaundice. Abdominal computed tomography showed ascites, bile duct dilatation and fluid collection under the liver (10 cm in diameter). Emergency surgery was performed to drain the fluid. On laparotomy, encapsulated biliary ascites was seen. To search for the site of the leak, after cholecystectomy, a tube (C-tube) was inserted into the common bile duct via cystic duct stump. Because of uncontrollable bleeding, after packing with surgical gauze, the operation was temporarily stopped. The next day, reoperation was performed. Intraoperative cholangiography with contrast dye revealed the perforation site in the left triangular ligament and a partial resection was performed. Bile excretion from the C-tube was subsequently observed, but the patient’s jaundice did not improve. Although endoscopic retrograde cholangiopancreatography revealed that the EST site was normal, ERBD was placed again, and the jaundice gradually improved. Although EST was performed in this case, biliary peritonitis resulting from spontaneous bile duct rupture occurred. This case was very informative because biliary perforation may occur even after EST.

Application of CT Image Scanning Technology Based on Iris Algorithm in Clinical Diagnosis of Patients with Hepatobiliary Stones

Objective: To investigate the value of multi-slice spiral CT in the diagnosis of extrahepatic bile duct stones using Iris algorithm. Methods: 66 cases of extrahepatic bile duct stones underwent plain and enhanced multiline spiral CT. Observe the density, size, location and number of stones during the plain scan. According to the venous phase enhanced scan, the extrahepatic bile duct wall ≥2 mm was used as the thickening criterion to evaluate the stone density, size, number, and composition ratio of the site and its relationship with tube wall thickening. Results: A total of 57 cases of stones of different densities were found on CT. Nine cases of stones of equal density were not identified. Among the 56 cases with thickened wall, 87.50% (49/56) were concentric and 12.50% (7/56) were eccentric. The wall thickening occurred 62.50% (35/56) below the stone; 17.86% (10/56) was located on the level or above the stone, and 8.93% (5/56) was above the stone. 6 cases (6/56) (10.71%) showed extensive tube wall thickening, all caused by multiple stones. Conclusion: In the study of extrahepatic bile duct stones using the Iris algorithm, it was found that most concentric circular tube wall thickening occurred on or below the stone level. When plain CT scan does not show clear bile duct stones, and this phenomenon appears in the portal vein phase of enhanced scan, the possibility of stones should be considered.

PATHOLOGICAL ALTERATION OF BALI CATTLE HEPATOBILIARY SYSTEM INFECTED WITH FASCIOLA GIGANTICA

Liver fluke infections is an important parasitic disease that common attack cattle, buffalo and others ruminant. The disease in the tropics is caused by Fasciola gigantica trematodes. Fasciolosis found in Bali cattle besides causing high economic loss also has the opportunity infect humans. This study aims to determine the pathology changes of Bali cattle hepatobiliary system infected by F. gigantica. In January 2019 were examined a hundred of liver tissue Bali cattle. Based on the sex as many as 75 bali cattle are cows and 25 are bulls. On macroscopic examination was found fifteen bali cattles in gallbladder containing of F. gigantica. In positive Fasciolosis the surface of liver look uneven with enlargement of lymph nodes. The tissue of Bali cattle liver infected with F. gigantica is cut into 1x1x1 cm and put in a pot that has been filled with 10% neutral buffered formaline. The fixed tissue then processed in a tissue processor and stained with hematoxylin-eosin (HE). Microscopic examination was found bile ducts proliferation and blocked of the lumen accompanied by cholangio cirrhosis. Found longitudinal pieces of Fasciola gigantica liver fluke surrounded by fibrous connective tissue and multifocal coagulative necrosis with fibroblast proliferation. In some location the infiltration of neutrophil cells around the bile ducts can also be seen. Congestion, bleeding, and neutrophil infiltration are also seen in areas of necrosis. In the bile duct wall bleeding, adenomatus hyperplasia, infiltration of mononuclear cells with mild intensity and foci of calcification are found. It can be concluded that there was a change with severe intensity accompanied by chronic inflammation in the hepatobiliary system of Bali cattle with Fasciolosis.

The Diagnosis of Autoimmune Pancreatitis Using Endoscopic Ultrasonography

Autoimmune pancreatitis (AIP) is characterized by enlargement of the pancreas and irregular narrowing of the main pancreatic duct. It is often associated with IgG4-related sclerosing cholangitis (IgG4-SC), in which the bile duct narrows. Although characteristic irregular narrowing of the pancreatic duct caused by endoscopic retrograde cholangiopancreatography is noted in AIP, it is difficult to differentiate between localized AIP and pancreatic carcinoma based on imaging of the pancreatic duct. While stenosis of the bile duct in IgG4-SC is characterized by longer-length stenosis than in cholangiocarcinoma, differentiation based on bile duct imaging alone is challenging. Endoscopic ultrasound (EUS) can characterize hypoechoic enlargement of the pancreas or bile duct wall thickening in AIP and IgG4-SC, and diagnosis using elastography and contrast-enhanced EUS are being evaluated. The utility of EUS-guided fine needle aspiration for the histological diagnosis of AIP has been reported and is expected to improve diagnostic performance for AIP. Findings in the bile duct wall from endoscopic retrograde cholangiopancreatography followed by intraductal ultrasonography are useful in differentiating IgG4-SC from cholangiocarcinoma. Diagnoses based on endoscopic ultrasonography play a central role in the diagnosis of AIP.