Case report: Obstructive jaundice caused by biliary cystadenoma

We herein report a case of a 56-year-old man with IgG4-related sclerosing cholangitis (IgG4-SC) with no biliary stricture, but with a severely thickened bile duct wall. Contrast-enhanced computed tomography showed diffuse swelling of the pancreas and thickening of the common bile duct (CBD) wall with delayed enhancement. Obvious diffuse wall thickening of the CBD was observed on endoscopic ultrasonography. However, endoscopic retrograde cholangiography showed no biliary stricture in the CBD that had thickened. Although IgG4-SC has been classified by a stenotic lesion on cholangiography, we should be aware of some IgG4-SC cases showing only bile duct wall thickness without any biliary stricture.

：Objective Tocomparatively study the ischemia-reperfusion injuries caused by heterogeneity of differentpositions of the biliary system and different construction patterns of the peribiliaryvascular plexus. Methods Thirty rats were randomly divided into 3 groups: Group Ⅰ , sham operated; Group Ⅱ, 1h ischemia inbiliary tract followed by 1h reperfusion; Group Ⅲ, 1h ischemia in biliarytract followed by 2h reperfusion. TUNEL assay, pathomorphology score determination andultrastructural quantitative analysis were performed on epithelium of the hilar bile duct,proximal common bile duct and interlobular bile duct. Results In groupⅡ , TUNEL assay and pathomorphology score showed no statisticaldifference between proximal common bile duct and interlobular bile duct (P＞0.05)but showed significant differences in the hilar bile duct(P＜0.05). Mean volume (V) ofmitochondria and area density of microvilli were obviously serious in the hilar bile ductbut obviously slight in the proximal common bile duct(P＜0. 05). In group Ⅲ,the results of the above detections showed that the most severe was in hilar bile duct,followed by the interlobular bile duct and proximal common bile duct(P＜0. 05). Conclusion Differentinjuries in various parts of the biliary system are caused by heterogeneity of biliaryepithelial cells and construction patterns of the peribiliary vascular plexus. It alsoprovides the experimental basis to explain the higher incidences of hilar bile ductstricture. It could be taken as the best position when the bile duct is anastomosed. Key words: Liver transplantation; Biliary tract; Ischemia-reperfusioninjury; Peribiliary vascular plexus; Rat

Background: Intraductal papillary neoplasm of the bile duct (IPMN-B) is a rare cystic neoplasm of the liver. This study retrospectively reviewed a relatively large sample of IPMN-B cases for diagnostic clinical or trans-abdominal ultrasound features. Methods: The medical records of 20 pathologically confirmed IPMN-B cases were reviewed. Serum concentrations of carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA), and alphafetoprotein (AFP) were evaluated, and images of conventional trans-abdominal ultrasound. According to the relationship between the hepatic mass and the dilated bile duct, we classified cases as type I–IV: I, non-tumor; II, asymmetrical; III, symmetrical; and IV, aneurismal dilation. The clinical and trans-abdominal ultrasound characteristics of these types were compared. Results: The clinical features were non-specific; only malignant cases showed CA19-9 or CEA elevation. Three, 9, 3, and 5 cases were types I, II, III, and IV, respectively, and the diameters of the dilated common bile ducts were 2.27±1.08, 1.82±0.79, 0.57±0.15, and 0.68±0.08 cm. The dilations of the common bile duct of types I and II were significantly larger than that of III and IV. Pathologically, 15, 3, and 2 cases were adenocarcinoma, benign, and two border adenomas. The pathological distribution among the four types differed significantly for all of the benign cases and 50% of the border adenomas were type I or II; types III and IV more aggressively progressed to adenocarcinoma. Conclusions: In patients with IPMN-B, the elevation of serum tumor markers may indicate malignant potential. The typical trans-abdominal ultrasound feature of IPMN-B was significant diffuse dilation of the intrahepatic and extrahepatic bile ducts, especially for benign cases. Some malignant cases only showed serious local bile duct dilation with IPMN. After exclusion of extrahepatic bile duct obstructive disease, IPMN-B should be suspected in patients with significant dilation of the bile duct.

An experimental model of anomalous arrangement of the pancreaticobiliary ducts (APBD) was produced by pancreaticocholecystostomy performed in 29 mongrel dogs. Our purpose was to study carcinogenesis of the extrahepatic biliary tract by DNA ploidy analysis with cytofluorometry. The amylase level in the bile was elevated in all 25 dogs tested except the controls. The phospholipase A2 level in the bile was elevated in all selected dogs except the controls. Common bile duct (CBD) dilatation was found in 23/29 (79%) of the dogs, and biliary stones were found in 3/29 (10%) dogs. Inflammatory changes were observed microscopically in all specimens except those from the controls. Intramural glandular structures were found in 17/25 (68%) of gallbladder (GB) specimens and 10/25 (40%) of CBD specimens; goblet cells were found in 7/25 (28%) of GB specimens and 2/25 (8%) of CBD specimens. In the controls neither glandular structures nor goblet cells were observed except for two GB specimens showing mild cholecystitis. Cytofluorometry showed 21% GB and 7% CBD diploidy, 69% GB and 65% CBD low ploidy, 10% GB and 28% CBD high ploidy patterns of histograms. These results show that, APBD may be central to high risk condition or play a key role to develop atypical biliary tract epithelium and DNA ploidy abnormality with or without biliary duct dilatation.

Objective To investigate the clinical features and treatment of residual gallbladder lesions after cholecystectomy. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 83 patients with residual gallbladder lesions after cholecystectomy who were admitted to the Affiliated Hospital of Inner Mongolia Medical University between January 2009 and April 2016 were collected. Among the 83 patients, 74 had residual gallbladder (41 combined with bile duct stones and 33 with simple residual gallbladder) and 9 had simple residual bile duct stones. Patients received laboratory and imaging examinations, and then selected suitable surgery according to residual lesions. Observation indicators included: (1) clinical features: medical history, clinical manifestation, features of laboratory and imaging examinations; (2) surgical and postoperative situations: surgical procedure, operation time, volume of intraoperative blood loss, time of drainage-tube removal, postoperative complications and duration of postoperative hospital stay; (3) postoperative pathological examination; (4) follow-up situation. Follow-up using outpatient examination and telephone interview was performed to detect survival of patients and recurrence of lesions using abdomen color Doppler ultrasound up to October 2016. Measurement data with normal distribution were represented as ±s. Results (1) Clinical features: ① medical history: all the 83 patients had histories of cholecystectomy, including 57 with emergency operation and 26 with selective operation. ② Clinical manifestation: initial clinical manifestation occurred at 1-324 months postoperatively, with an average time of 96 months. Of 83 patients, 49 had right upper abdominal colic associated with right shoulder or back rediating pain, fever, nausea and vomiting, 24 had jaundice as the main symptoms, 8 had gradually worse conditions, with right upper quadrant abdominal pain, chills and fever associated with jaundice in the advanced stage and 2 had abdominal discomfort associated with incomplete intestinal obstruction. ③ Laboratory examination: elevated alanine transaminase (ALT) and aspartate transaminase (AST) levels were detected in 48 patients, elevated total bilirubin (TBil) level in 28 patients and elevated serum and urinary amylase level in 4 patients, respectively. ④ Imaging examination: of 83 patients, 77 had positive results of magnetic resonanced cholangio-pancreatography (MRCP), 43 had positive results of abdominal color Doppler ultrasound and 39 (4 combined with pancreatitis) had positive results of abdominal computed tomography (CT). (2) Surgical and postoperative situations: all the 83 patients underwent surgery. Of 74 patients with residual gallbladder, 72 underwent residual gallbladder resection (of 41 combined with bile duct stones, 35 undergoing residual gallbladder resection + bill duct exploration and removing the stone + T-tube drainage, 6 initially undergoing endoscopic sphincterotomy for removing bile duct stones and then residual gallbladder resection and 31 undergoing simple residual gallbladder resection), 1 combined with residual gallbladder cancer underwent residual gallbladder resection + common bile duct resection + hepatic duct-jejunum internal drainage and 1 combined with residual gallbladder cancer and common bile duct space-occupying lesion underwent palliative biliary-enterostomy. Nine patients with simple residual bile duct stones underwent endoscopic sphincterotomy for removing bile duct stones. Operation time, volume of intraoperative blood loss, time of drainage-tube removal and duration of postoperative hospital stay were (92±39)minutes, (63±12)mL, (5±4)days and (9±5)days in 74 patients with residual gallbladder, respectively. There was no severe postoperative complication. Operation time, volume of intraoperative blood loss and duration of postoperative hospital stay were (57±33)minutes, (25±9)mL and (5±3)days in 9 patients with simple residual bile duct stones, respectively. No severe complication was occurred in 9 patients. (3) Postoperative pathological examination: the length of residual cystic duct in 74 patients with residual gallbladder was (2.8±1.0)cm, combining with stones. Of 74 patients, simple hyperplasia of residual gallbladder were detected in 54 patients, dysplasia in 14 patients, tumor-like hyperplasia and benign tumor in 4 patients and adenocarcinoma in 2 patients. (4) Follow-up situation: all the 83 patients were followed up for 6-71 months, with a median time of 33 months. Eighty-one patients were healthy survival, without recurrence of lesions. One patient had recurrence of bile duct stones at 34 months postoperatively, and then was cured by choledochojejunostomy, without recurrence up to the end of follow-up. One patient with residual gallbladder cancer complicated with common bile duct space-occupying lesion died at 9 months postoperatively. Conclusions Patients have recurrent right upper abdominal colic associated with right shoulder or back rediating pain, fever and jaundice after cholecystectomy, and lesions of residual gallbladder or bile duct stones should be considered. Reoperation is safe and feasible for patients, with a good clinical outcome. Key words: Remnant gallbladder; Cholelithiasis; Cholecystectomy

Gallstone disease is one of the most common diseases of the gastrointestinal tract. When gallstones enter the bile duct, they can cause obstruction of the bile ducts, which leads to jaundice, cholangitis, and obstruction of the common bile duct can even lead to pancreatitis. Moreover, gallstones can result in such serious complications as biliary perforation, biliary fistulas and neoplasms. In the case of Mirizzi syndrome, the common bile or hepatic ducts are externally compressed by calculi in the neck of the gallbladder, and in Bouveret syndrome, acute small intestinal obstruction occurs as a result of gallstone blockage. Today, laparoscopic cholecystectomy is considered to be the main method for treating gallstone disease. Complications that arise during or after such surgical interventions can include internal bleeding, damage to the bile ducts or intestines, blockage of the common bile duct by calculi, postoperative hernias, etc. The aim of this study is to present a clinical case of successful surgical management of a cholecystocholedochal fistula, and to inform practitioners interested in this condition about the specific features of the surgical approach used. This report describes a patient with one of the most serious complications of gallstone disease, fistula formation between the gallbladder and the common bile duct. The patient underwent laparoscopic cholecystectomy, followed by reconstruction of the common bile duct defect using polyglycolide suture material. The choledochus was drained through a separate incision. The choledochotomy opening was sutured with a double-row suture using polyglycolide suture with fixation of the tube, which was brought out. External drainage of the choledochus was performed for one month. A month later, a control cholangiofistulography was performed to ensure that the contrast agent freely entered the duodenum, and then the external drainage of the choledochus was removed. As a result of the surgery, the choledochal defect was closed, and the patency of the bile ducts was preserved.

BackgroundMucinous cystic neoplasm of the liver (MCN-L) is a rare cystic tumor as defined by the 2010 World Health Organization classification. MCN-L usually does not communicate with or grow into the bile duct. Herein, we present a rare case of MCN-L with a polypoid nodule protruding into the bile duct.Case presentationA 69-year-old woman was referred to our hospital for elevated serum liver enzyme levels and obstructive jaundice. The patient also complained of abdominal pain in the right hypochondriac region. Abdominal ultrasonography showed a cystic lesion in segment 4 (S4) of the liver. Computed tomography revealed a 4-cm multilocular cystic lesion with a thick wall and multiple septal formations, showing a cyst-in-cyst appearance in S4. Endoscopic retrograde cholangiography showed a contrast defect between the left hepatic duct and the common bile duct, which was suspected to be a nodular lesion in the bile duct. Bile cytology and biopsy of the nodular lesion showed no malignant findings. Based on these findings, the differential diagnosis in this patient included intraductal papillary neoplasm of the bile duct and MCN-L, which had malignant potential. The patient underwent left hemihepatectomy, including caudate lobe excision with bile duct resection and right hepatocholangiojejunostomy. Macroscopic findings showed a 40 × 29 mm multilocular cystic lesion with a polypoid nodule that protruded into the left intrahepatic bile duct. As an ovarian-like stroma was observed in both cystic and polypoid lesions microscopically, the histopathological diagnosis was MCN-L. The postoperative course was uneventful, and the patient was discharged 24 days after surgery. The patient is currently alive without recurrence 22 months after the surgery.ConclusionAlthough MCN-L rarely communicates with the bile duct, it is necessary to consider that MCN-L could grow into the bile duct, occasionally causing obstructive jaundice.

BackgroundFollicular cholangitis (FC) is a benign bile duct disease that was first reported 2003. Pathologically, it is characterized by lymphoplasmacytic infiltration with multiple lymphoid follicle formations under the mucosal layer of the biliary tract. However, as this disease is extremely rare, little is known about its etiology and pathogenesis.Case presentationA 77-year-old woman was diagnosed with middle bile duct stenosis and potential increases in alkaline phosphatase (ALP) and γ-glutamyl transpeptidase levels (γ-GTP). Carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9) and IgG4 levels were all within the normal limits. Contrast-enhanced computed tomography (CE-CT) and magnetic resonance imaging (MRI) revealed bile duct dilation from intrahepatic to upper common bile duct and an irregular mass lesion in distal bile duct. Additionally, multiple overlapping leaf-like folds were detected. 18F-fluorodeoxyglucose positron emission tomography–computed tomography (18F-FDG-PET/CT) did not demonstrate fluorodeoxyglucose uptake. Subtotal stomach-preserving pancreaticoduodenectomy with regional lymph node dissection was performed because common bile duct cancer could not be ruled out. The resected specimen showed diffuse homogeneous middle bile duct wall thickening. Microscopically, the lesion exhibited thick fibrosis with several invaded lymphoplasmacytic cells, and lymphoid follicle formations were detected under the mucosal layer. Immunohistochemical staining (IHC) revealed positive for CD3, CD4, CD20 and CD79a, and these findings led to a final diagnosis of FC. The patient has not experienced recurrence to date (42 months postoperatively).ConclusionsCurrently, accurate preoperative diagnosis of FC is difficult. More cases must be accumulated to generate additional knowledge on its precise diagnosis and proper treatment.

Background: Biliary cystadenomas are rare cystic tumors of the bile duct system that are mostly benign but also have the possibility of malignant transformation. Biliary cystadenomas mostly occur in the intrahepatic bile ducts and are more common in middle-aged women. Due to non-specific radiology, preoperative diagnosis is difficult and is usually performed by postoperative pathology. Complete resection is the best treatment option, and the postoperative prognosis is good.Case Description: This study reports a case of a patient with biliary cystadenoma who was diagnosed with simultaneous chronic hepatitis B and colon (hepatic flexure) adenomatous polyps. The patient presented to the doctor because of abdominal pain, and a blood test showed hepatitis B. Computed tomography revealed both right liver and colonic lesions. Colonoscopy revealed polyps, and the postoperative pathological diagnosis was adenomatous polyps. Laparoscopic resection of the right liver tumor was performed, and it was diagnosed as hepatobiliary cystadenoma by postoperative pathological analysis combined with immunohistochemistry.Conclusion: In patients with chronic hepatitis, the shape of biliary cystadenoma may not be very typical, and it is necessary to combine this with immunohistochemistry for diagnosis. When multiple lesions are detected in the painful area, the diagnosis of each lesion and its treatment sequence are worthy of consideration. Under normal circumstances, the prognosis of biliary cystadenoma is good; however, in patients with chronic hepatitis B, more cases need to be observed for verification.

Introduction: biliary cystadenomas are rare benign cystic lesions of biliary origin with potential of malignancy. Mostly occurring in women (90%) with non-specific symptoms. case report: We presented a very rare case of biliary cystadenoma in hilar region causing episodic biliary obstruction. A 60-year-old female with episodic obstructive jaundice was evaluated and diagnosed as having cystic lesion near the hilum of liver. With differential diagnosis of biliary cystadenoma or hydatid cyst, she underwent laparotomy. Intraoperatively the cystic lesion was found in the segment IVb with communication into the hilar region as pedunculated polypoid lesion, which was occluding the lumen causing

Acute Hemobilia and Hemocholecyst in 2 Dogs with Gallbladder Carcinoid

Objective To study the possible mechanisms of pathogenesis of congenital biliary dilatation and to classify the disease accordingly. Methods The clinical data of 107 children with congenital biliary dilatation and pancreaticobiliary malunion who underwent surgery at this center between October 2000 and October 2009 were studied. Radiologic features of congenital biliary dilatation and pancreaticobiliary malunion were examined and correlated with laboratory results. Relative lengths/diameters were calculated to provide comparison between children of different ages. Intraluminal pressures of common bile duct (CBD) were measured intraoperatively. Results The minimal relative diameters of distal CBD negatively correlated with the maximal relative diameters/lengths of dilated CBD, the maximal relative diameters of common hepatic duct, and left/right hepatic ducts. The intraluminal pressure including resting pressure and perfusion pressure in patients with a stenotic distal CBD (stenotic group) was significantly higher than that in patients with a nonstenotic distal CBD (nonstenotic group). The narrower the distal CBD, the more deranged the liver function. Conversely, serum/bile amylase levels were more elevated in the nonstenotic group (serum amylase, 660 ± 212 U/L vs. 104 ±77 U/L, P＜0.001; bile amylase, 77354 ± 43759 U/L vs. 2398 ± 1173 U/L, P＜0.001). Common channel protein plugs were only found in the nonstenotic group, whereas common hepatic duct strictures, intrahepatic duct dilatations, and calculi were detected more frequently in the stenotic group. Conclusions We propose to categorize congenital biliary dilatation into 2 subgroups:(1) cystic type with stenotic distal CBD associated with deranged liver function and common hepatic duct stricture and (2) fusiform type with nonstenotic distal CBD associated with pancreatitis and common channel protein plugs. Different underlying pathologies of each group require different operative strategies. Key words: Cholangiectasis; Pancreatitis

Although polycystic liver disease (PLD) is known to be associated with autosomal dominant polycystic kidney disease, a finding of PLD with pancreatic ductal adenocarcinoma is extremely rare. We have experienced one such case of a ductal adenocarcinoma of the pancreas in a patient with Potter type III cystic disease of the liver and kidney. A 63-year-old man was admitted to our hospital because of obstructive jaundice. Six months previously, on admission to a local hospital for treatment of diabetes mellitus, he had been found to have polycystic disease of the liver and kidney. Ultrasound examination revealed dilatation of the intrahepatic bile duct and the common bile duct. Blood tests showed an elevated total bilirubin level. Abdominal computed tomography scans and magnetic resonance imaging demonstrated polycystic lesions in the liver and the bilateral kidneys. Percutaneous transhepatic cholangio-drainage was performed, and fluorography of the biliary tree revealed obstruction of the lower common bile duct, causing jaundice. This appears to be a case of independent association of pancreatic ductal adenocarcinoma with polycystic disease of the liver and kidney. The patient's sister, who also had polycystic disease of the liver and kidney, had died of squamous cell carcinoma of the tongue. Although familial associations of carcinomas with polycystic liver disease may be extremely rare, they provide a perspective for the etiology of polycystic liver disease.

The objective of this report was to study the sensitivity of indicators used for predicting bile duct stones and their endoscopic removal before laparoscopic cholecystectomy. A retrospective study was conducted on 104 patients who successfully underwent endoscopic retrograde cholangiopancreatogram (ERCP) before laparoscopic cholecystectomy at Riyadh Medical Complex between 1992 and 1994 (1412H-1414H). Six indicatorsâjaundice, biliary pancreatitis, stones in bile duct on sonography, dilated bile duct (>7 mm) on ultrasonography, dilated bile duct with deranged liver function test, and deranged liver function test without jaundiceâwere used for suspecting choledocholithiasis and endoscopic removal before laparoscopic cholecystectomy. Ultrasound correctly predicted bile duct stone in 75%, followed by dilated bile duct with deranged liver function test (46%). Clinical jaundice and biliary pancreatitis were equally sensitive indicators (42% each). Sensitivity of only dilated bile duct on ultrasonography in predicting duct stone was 36%. Deranged liver function without jaundice was the least sensitive (22%) of the predictors. Overall, these indicators correctly diagnosed bile duct stones in 34% of patients. Until laparoscopic exploration of bile duct or a noninvasive technique, such as magnetic resonance cholangiopancreatogram (MRCP), is widely available, these predictors will help in selecting patients with bile duct stones for preoperative removal. Other workers have suggested combining these indicators to improve the predictive value.

A 35-year-old female presented with complaints of several episodes of malaena and frank blood in the stools for the past 1 year. The frequency of these episodes had increased in the past 2 months. The patient complained of extreme weakness and palpitations. There was no history of abdominal pain, nausea, vomiting or haematemesis. There was no history of fever, jaundice, weight loss or constipation. Physical examination was unremarkable except for the presence of severe pallor. Digital rectal examination revealed black tarry stools staining the glove. There was no palpable growth; first degree haemorrhoids were visible at the 3 o'clock position; no active bleeding was discernible. Her haemoglobin was 4 g dl−1, packed cell volume 12.5%, total leukocyte count 7900 cells mm−3and platelet count 5.34×105 mm−3. Peripheral smear showed features of anaemia. Total serum bilirubin was 2.5 mg dl−1 (direct bilirubin 1.2 mg dl−1). The rest of the liver function tests were within normal limits. HBsAg (the surface antigen of the hepatitis B virus) was negative and human immunodeficiency virus was non-reactive. A chest radiograph demonstrated mild cardiomegaly and the lung fields were clear. Colonoscopy was within normal limits. An upper gastrointenstinal endoscopy was performed, which showed a normal stomach and first part of duodenum. The endoscope could not be negotiated into the third part of the duodenum. A barium meal examination was done for further evaluation of the upper gastrointestinal tract. Two radiographs of an upper gastrointestinal barium series are shown (Figure 1). Figure 1 (a) Barium meal upper gatsrointestinal tract: smooth narrowing or “beaking” at the junction of the second and third parts of the duodenum, with mucosal folds running parallel to the lumen and a small C-loop of the duodenum. (b) Barium ...