Nasobiliary drainage: an effective treatment for pruritus in cholestatic liver disease

IntroductionNasobiliary drains (NBDs) have been successfully used to manage intrahepatic cholestasis, bile leaks and obstructive cholangitis. It allows external drainage of bile, bypassing the ileum where bile salts are reabsorbed. We assessed the utility of placement with effect on markers of cholestasis and patient symptoms.MethodsConsecutive patients undergoing NBD over 12 years for the management of pruritus were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and response to therapy.ResultsTwenty-three patients (14, 61% male) underwent 30 episodes of NBD. The median age was 26 years old (range 2–67 years old). A single procedure was carried out in 20. One patient each had two, three and five episodes of NBD. The most common aetiologies were hereditary cholestatic disease (n=17, 74%) and drug-induced cholestasis (n=5, 22%),NBD remained in situ for a median of 8 days (range 1–45 days). Significant improvement in bilirubin was seen at 7 days post-NBD (p=0.0324), maintained at day 30 (335 μmol/L vs 302 µmol/L vs 167 µmol/L). There was symptomatic improvement in pruritus in 20 (67%, p=0.0494) episodes. One patient underwent NBD during the first trimester of pregnancy after medical therapy failure with a good symptomatic response. The catheters were well tolerated in 27 (90%) of cases. Mild pancreatitis occurred in 4 (13%) cases.ConclusionNBD can be used to provide symptomatic improvement to patients with pruritus associated with cholestasis. It is well tolerated by patients. They can be used in pregnancy where medical management has failed.

The Difficult Path to Correct Diagnosis of Hepatolithiasis: A Case Report

Hepatolithiasis is a benign disease, where stones are localized proximal to the confluence of hepatic ducts. The clinical picture may differ depending on whether the stones cause complete, partial, or intermittent biliary obstruction. The course can vary from asymptomatic to fatal, thus, early diagnosis and treatment is critical for a good prognosis. The gold standard in imaging is magnetic resonance cholangiopancreatography (MRCP). However, correct diagnosis can be challenging due to atypical clinical picture and laboratory findings. We present a case where hepatolithiasis was misdiagnosed initially due to incomplete reporting and documentation of MRCP. Choledocholithiasis was diagnosed based on initial MRCP, and endoscopic stone extraction was indicated. However, an unusual post-interventional course and signs of obstructive cholangitis led to an endoscopic re-intervention, which confirmed absence of pathology in extrahepatic biliary ducts. The cholangitis recurrence required intensive antibiotic treatment, and CT examination revealed intrahepatic S3 bile duct dilatation. Thus, a re-evaluation of initial MRCP and repeated MRCP confirmed hepatolithiasis. Further, laparoscopic bisegmentectomy was chosen as the definitive treatment due to the location of the lesion. The patient recovered and remained symptom free upon a 12 month follow up.

Acute obstructive cholangitis due to fishbone in the common bile duct: a case report and review of the literature

Background Choledocholithiasis is an endemic condition in the world. Although rare, foreign body migration with biliary complications needs to be considered in the differential diagnosis for patients presenting with typical symptoms even many years after cholecystectomy, EPCP, war-wound, foreign body ingestion or any other particular history before. It is of great clinical value as the present review may offer some help when dealing with choledocholithiasis caused by foreign bodies. Case presentation We reported a case of choledocholithiasis caused by fishbone from choledochoduodenal anastomosis regurgitation. Moreover, we showed up all the instances of choledocholithiasis caused by foreign bodies published until June 2018 and wrote the world’s first literature review of foreign bodies in the bile duct of 144 cases. The findings from this case suggest that the migration of fishbone can cause various consequences, one of these, as we reported here, is as a core of gallstone and a cause of choledocholithiasis. Conclusion The literature review declared the choledocholithiasis caused by foreign bodies prefer the wrinkly and mainly comes from three parts: postoperative complications, foreign body ingestion, and post-war complications such as bullet injury and shrapnel wound. The Jonckheere-Terpstra test indicated the ERCP was currently the treatment of choice. It is a very singular case of choledocholithiasis caused by fishbone, and the present review is the first one concerning choledocholithiasis caused by foreign bodies all over the world.

Monitoring of impaired phagocytic function of Kupffer cells in an obstructive cholangitis rat model using superparamagnetic iron oxide MRI and contrast-enhanced ultrasound

Background Kupffer cells (KC) have an important role in the host defense in obstructive cholangitis. Non-invasive monitoring of phagocytic function of KC is pivotal. Several studies showed the possibility of non-invasive monitoring of phagocytic function of KC using superparamagnetic iron oxide-enhanced magnetic resonance imaging (SPIO-MRI) or contrast-enhanced ultrasound (CEUS). Purpose To investigate the serial change of KC function using SPIO-MRI and CEUS and whether the SPIO-MRI parameter correlates with the CEUS parameter in obstructive cholangitis rat models. Material and Methods With our institutional Animal Care and Use Committee approval, 19 rats (common bile duct ligation [CBDL]: n = 9; control: n = 10) underwent SPIO-MRI and CEUS at baseline, two, and four weeks after CBDL. The relative signal loss (RSL) of T2* value on SPIO-MRI and Kupffer phase parenchymal echogenicity (KPE) on CEUS were measured. The correlation between SPIO-MRI and CEUS parameters were compared with KC count. Results In CBDL group, RSL and KPE had significantly decreased (72.1% to 29.5%, 2.7 to 0.4) at four weeks compared with those in the control group (68.2% to 58.3%, 2.5 to 3.0, P < 0.05). During the follow-up period, RSL showed significantly positive correlations with KPE ( P = 0.007). In addition, at four weeks, we found RSL was positively correlated with KPE (ρ = 0.750, P = 0.002). KC count was negatively correlated to RSL and KPE at four weeks (ρ = −0.771, P = 0.001 and ρ = −0.644, P = 0.013). Conclusion SPIO-MRI and CEUS may be equally useful for monitoring the serial changes of KC phagocytic function in vivo.