Perforación espontánea de la vía biliar en un neonato: un hallazgo inesperado: caso clínico / Spontaneous perforation of the bile duct in a neonate: an unexpected finding: case report

La perforación espontánea de la vía biliar extrahepática es rara en recién nacidos. Es una causa quirúrgica de ictericia en este período y la presentación aguda es inusual. OBJETIVO: presentar un caso de perforación espontanea de la vía biliar en un recién nacido por sus graves complicaciones si no se realiza un diagnóstico temprano y oportuno. CASO CLÍNICO: Recién nacido de término de 10 días de vida que consultó por cuadro de rechazo alimentario, fiebre y distensión abdominal de 2 días de evolución, sin ictericia, acolia, ni coluria. En los exámenes de laboratorio se encontró leucopenia, trombocitosis y elevación de la proteína C reactiva, con función hepática normal. La radiografía de abdomen demostró neumoperitoneo, sospechándose enterocolitis necrosante, se realizó laparotomía, encontrándose perforación espontánea de la vía biliar extrahepática y peritonitis biliar. La colangiografía intraoperatoria demostró la vía biliar proximal rescatable y conducto cístico dilatado. Se realizó hepático-yeyunostomía con Y de Roux transmesocolónica y colecistectomía. En el estudio postoperatorio se encontró trombosis portal, por lo que recibió tratamiento anticoagulante. En el control a los ocho meses de edad, la paciente tenía buena tolerancia oral y adecuado incremento ponderal. CONCLUSIONES: La perforación biliar es una entidad rara y más en el período neonatal, condición que la vuelve un reto diagnóstico y terapéutico. El pronóstico dependerá de la intervención temprana y los hallazgos intraoperatorios.

Spontaneous extrahepatic bile duct perforation is rare in newborns. It is a surgical cause of jaundice in this period and the acute presentation is unusual. OBJECTIVE: To report a case of spontaneous bile duct perforation in a newborn due to its serious complications if an early and timely diagnosis is not performed. CLINICAL CASE: A 10-day-old newborn who developed food rejection, fever and abdominal distension without jaundice, acolia, or coluria two days prior of admission. The laboratory tests showed leukopenia, thrombocytosis, increased C-reactive protein, and normal hepatic function. The abdominal x-ray showed pneumoperitoneum, and the diagnosis of necrotizing enterocolitis was made. Laparotomy was performed; extrahepatic bile duct perforation and biliary peritonitis were noted. Intraoperative cholangiography demonstrated rescatable proximal bile duct and dilated cystic duct. Hepatic-jejunostomy was performed with Roux-en-Y and cholecystectomy. In the postoperative study portal thrombosis was found, so he received anticoagulant treatment. At 8 months of age, the patient had enteral feeding tolerance and adequate weight gain. CONCLUSIONS: Biliary perforation is a rare entity and more in the neonatal period, a condition that makes it a diagnostic and therapeutic challenge. The prognosis will depend on early intervention and intraoperative findings.

Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea

PURPOSE: Cholecystectomy in patients with an intact gallbladder after endoscopic removal of stones from the common bile duct (CBD) remains controversial. We conducted a case-control study to determine the risk of recurrent CBD stones and the benefit of cholecystectomy for prevention of recurrence after endoscopic removal of stones from the CBD in Korean patients. MATERIALS AND METHODS: A total of 317 patients who underwent endoscopic CBD stone extraction between 2006 and 2012 were included. Possible risk factors for the recurrence of CBD stones including previous cholecystectomy history, bile duct diameter, stone size, number of stones, stone composition, and the presence of a periampullary diverticulum were analyzed. RESULTS: The mean duration of follow-up after CBD stone extraction was 25.4+/-22.0 months. A CBD diameter of 15 mm or larger [odds ratio (OR), 1.930; 95% confidence interval (CI), 1.098 to 3.391; p=0.022] and the presence of a periampullary diverticulum (OR, 1.859; 95% CI, 1.014 to 3.408; p=0.045) were independent predictive factors for CBD stone recurrence. Seventeen patients (26.6%) in the recurrence group underwent elective cholecystectomy soon after endoscopic extraction of CBD stones, compared to 88 (34.8%) in the non-recurrence group; the difference was not statistically significant (p=0.212). CONCLUSION: A CBD diameter of 15 mm or larger and the presence of a periampullary diverticulum were found to be potential predictive factors for recurrence after endoscopic extraction of CBD stones. Elective cholecystectomy after clearance of CBD stones did not reduce the incidence of recurrent CBD stones in Korean patients.

El retrato de una lesión de la vía biliar / Portrait of a Bile Duct Injury

El contacto entre la cirugía y la tecnología tuvo su cúspide a finales del siglo XX con el advenimiento de la cirugía laparoscópica. En 1989 Jacques Perissat presentó su técnica de colecistectomía laparoscópica a la Sociedad Americana de Cirujanos Endoscópicos y Gastrointestinales (SAGES), en Louisville Kentucky. Este evento fue el punto de partida que posteriormente siguió el futuro de la cirugía mínimamente invasiva a nivel mundial. El objetivo de éste artículo, es mostrar los distintos escenarios en los que durante una colecistectomía laparoscópica incluso el cirujano más hábil puede verse inmerso: la identificación de una lesión de la vía biliar.

With the advent of laparoscopic surgery toward the end of the 20th Century, the merging of surgery and technology attained new heights. In 1989 JaquesPerissant presented his technique for laparoscopic cholecystectomy at the meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Louisville , Kentucky. This was the starting point for what was to become in the future the worldwide use of minimally invasive surgery. The aim of this article is to describe those scenarios which, even in the ablest hands, can lead to a bile duct injury during laparoscopic cholecystectomy.

Monosegmental Hepatobiliary Fibropolycystic Disease Mimicking a Mass: Report of Three Cases

Hepatobiliary fibropolycystic diseases are a unique group of entities involving the liver and biliary tract, which are caused by abnormal embryologic development of the ductal plates at various stages. We experienced strange hepatobiliary fibropolycystic diseases with a complex mass composed of malformed ducts and biliary cysts, which did not belong to, and were different from, previously known malformations. They were unique in imaging and histologic features. We herein report three cases of monosegmental hepatobiliary fibropolycystic disease mimicking a mass.

RE: Communication between the Cystic Lesions of the Liver and Biliary Tree: How Can We Evaluate Efficiently and Safely?

No abstract available.

Vanishing bile duct syndrome in a Hodgkin's lymphoma patient with fatal outcome despite lymphoma remission

Vanishing bile duct syndrome [VBDS] is a condition resulting from severe bile duct injury, progressive destruction, and disappearance of intrahepatic bile ducts [ductopenia] leading to cholestasis, biliary cirrhosis, and liver failure. VBDS can be associated with a variety of disorders, including Hodgkin's lymphoma [HL]. We describe a 33-year-old male patient who presented with lymphadenopathy and jaundice, and was diagnosed to have HL. Serum bilirubin worsened progressively despite chemotherapy, with a cholestatic pattern of liver enzymes. Diagnosis of VBDS was established on liver biopsy. Although remission from HL was achieved, the patient died of liver failure. Presence of jaundice in HL patients should raise the possibility of VBDS. This report discusses the difficulties of delivering chemotherapy in patients with liver dysfunction. HL-associated VBDS carries a high mortality but lymphoma remission can be achieved in some patients. Therefore, liver transplantation should be considered early in these patients.

Biliary Peritonitis after Radiofrequency Ablation Diagnosed by Gadoxetic Acid-Enhanced MR Imaging

This study describes the first case of biliary peritonitis after radiofrequency ablation diagnosed by magnetic resonance (MR) imaging with gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA), a hepatocyte-specific MR imaging contrast agent. The image acquired 300 minutes after the administration of Gd-EOB-DTPA was useful to make a definite diagnosis and to identify the pathway of bile leakage. It is important to decide on the acquisition timing with consideration of the predicted location of bile duct injury.

PCRE: ampulotomía o fistulotomía suprapapilar con needle knife para acceder a la vía biliar en canulación dificil / ERCP: ampulotomy or suprapapillary fistulotomy with needle knife to access bile ductin difficult cannulation

INTRODUCCIÓN: la canulación profunda de la via biliar principal es requisito para una Pancreato-colangiografía Retrograda Endoscópica (PCRE) de carácter terapéutico. El pre corte es una técnica practicada en casos de canulación difícil. Objetivo: Reportar los casos de pacientes con canulación difícil y fistulotomia suprapapilar como un método para la canulación selectiva del colédoco. Reportar la eficacia, hallazgos demográficos, endoscópicos y complicaciones de éste procedimiento. MATERIAL Y MÉTODOS: estudio prospectivo, descriptivo y observacional de casos. Se ha realizado en 93 pacientes sometidos a PCRE con canulación difícil en quienes se practicó el pre corte tipo Fistulotomia, en un Centro privado de Endoscopia Digestiva del 2000 al 2010 en Lima. RESULTADOS: En 1205 (100%) CPRE se hicieron 1152 (96%) papiloesfinterotomias, de éstos en 93 casos (8%) casos se hizo fistulotomia previa a la papiloesfinterotomia. El grupo atareo más frecuente fue de 61 a 70 años, la relación F:M, 2.4:1. La eficacia fue 96%, los hallazgos endoscópicos más frecuentes fueron Odditis, impactación de cálculo y la presencia de ampuloma, los diagnósticos finales fueron enfermedad litiásica (34%), seguida de la Odditis con o sin litiasis coledociana (29%), en el 75% de casos se realizó terapéutica, el 8.5% de casos presentó complicaciones (pancreatitis y sangrado). No se registró perforaciones ni colangitis. CONCLUSIONES: en esta serie la fistulotomia en casos de canulación difícil es eficaz, es más frecuente en casos de Odditis, cálculo impactado y ampuloma y las complicaciones son bajas. RECOMENDACIONES: el pre corte tipo fistulotomia está dirigida a pacientes que requieren PCRE terapéutica, la decisión de realizarla debe ser precoz, la firma de un consentimiento informado es primordial.

INTRODUCTION: Biliary conducts deep cannulation is a requirement for therapeutic Endoscopic Retrograde Cholangio-Pancreatography (ERCP). The pre-cut papillotomy is a technique for difficult cannulation cases. Aims: Report cases of hard cannulation and suprapapilar fistulotomy as a method for selective common bile duct cannulation. Report efficacy, demographic and endoscopic findings and complications of this procedure. MATERIALS AND METHODS: Observational, descriptive and prospective study of cases. Sample of 93 patients who had a difficult cannulation ERCP, in which suprapapilar fistulotomy pre-cut type was done, in a private digestive endoscopic center between 2000 and 2010 in Lima, Peru. RESULTS: 1205 (100%) ERCP were made 1152 (96%) papillosphincterotomies. Fistulotomy was done in 93 cases (8%) of these papillosphincterotomies. The most prevalent age group was 61 to 70 years old, the female-male proportion was 2.4:1. The efficacy was 96%. The most prevalent endoscopy findings were odditis, gallstone impactation and ampulloma presence, final diagnosis were lithiasic disease (34%), Odditis with or without common bile duct lithiasis (29%). Therapeutic ERCP was done in 75% of the cases, 8.5% showed complications (pancreatitis and bleeding). No perforation or cholangitis were registered. CONCLUSIONS: In this case series, fistulotomy in difficult cannulation procedures had good efficacy. Is most prevalent in cases with odditis, gallstone impactation and ampulloma. Complications of the procedure are low. RECOMMENDATIONS: The fistulotomy type of pre-cut is leaded for patients who require therapeutic ERCP. The decision for doing the procedure must be precocious and informed consent is primordial.

Portal Bilopathy / 대한소화기학회지

No abstract available.

Biliary Cast Syndrome in Non-Liver Surgery Patients / 대한소화기학회지

Biliary cast describes the presence of casts within the biliary tree. It is resultant sequel of cholangitis and hepatocyte damage secondary to bile stasis and bile duct injury. Biliary cast syndrome was first reported in patient undergone liver transplantation. The pathogenesis of biliary cast is not clearly identified, but proposed etiologic factors include post-transplant bile duct damage, ischemia, biliary infection, or post-operative biliary drainage tube. Although biliary casts are uncommon, most of biliary cast syndrome are reported in the liver transplant or hepatic surgery patients. A few reports have been published about non-transplant or non-liver surgery biliary cast. We report two cases of biliary cast syndrome in non-liver surgery patients.

Curso de atualização em emergências médicas: aula 20: colangite aguda: diagnóstico e terapêutica / Updating medical emergencies course: class 20: acute cholangitis: diagnostic and therapeutic

A colangite aguda corresponde à infecção ascendente das vias biliares e geralmente está relacionada com as bactérias entéricas - gram-negativas, anaeróbios e enterococos. O fator patogênico mais importante é o obstrutivo, pois a presença de bactérias na bile não é suficiente para causar infecção das vias biliares se não estiver presente o componente obstrutivo. Dentre eles, a coledocolitíase é o principal elemento em cerca de 70% a 80% dos casos. Clinicamente, a tríade clássica - febre com calafrios, dor do hipocêndrio direito e icterícia - descrita por Charcot em 1877 manifesta-se em cerca de 70% a 80% dos pacientes. A ultrassonografia abdominal (e mais raramente a colangiopancreatografia por ressonância magnética) deve ser o método de escolha, por ser hábil em detectar dilatação da via biliar acima do local da obstrução e também por poder revelar sua causa. A terapêutica da colangite bacteriana aguda deve alicerçar-se na ressuscitação volêmica, antibioticoterapia e desobstrução da via biliar com consequente drenagem, sendo esta última a pedra angular da terapia emergencial da colangite aguda, que pode ser feita por via endoscópica (CPRE) ou transparietal (PTC).

Acute cholangitis corresponds to the ascending infection of the biliary tract and is usually associated with enteric bacteria - gram-negative, anaerobes and enterococci. The most important pathogenic factor is the obstruction because the presence of bacteria in bile is not sufficient to cause infection of the biliary tract in the absence of one obstructive component. Among these, choledocholithiasis is the main element in about 70% to 80% of cases. Clinically, the classic triad - fever with chills, pain in the right hypochondrium and jaundice - described by Charcot in 1877, manifests itself in about 70% to 80% of patients. The abdominal ultrasound (and, less frequently, magnetic resonance cholangiopancreatography) should be the method of choice because it is able to detect bile duct dilation above the site of the obstruction and also to reveal its cause. The treatment of acute bacterial cholangitis must be based on fluid resuscitation, antibiotics and clearing of the bile duct with subsequent drainage, the latter being the cornerstone of emergency therapy of acute cholangitis, which can be performed endoscopically (ERCP) or transparietal (PTC).

Pancreatite na gestação / Pancreatitis in pregnancy

Pancreatite caracteriza-se por processo inflamatório do pâncreas, apresentando ruptura da membrana celular e proteólise tecidual, seguida da ativação de células da resposta imunológica. É uma afecção de amplo espectro clínico e apresenta variadas etiologias. Durante a gestação, merece devida relevância em função da alta morbi-mortalidade que a acompanha. A litíase das vias biliares é o fator etiológico predominante na patogênese da pancreatite aguda durante a gravidez, sendo que as gestantes podem desenvolver pancreatite aguda associada à hiperlipidemia. O diagnóstico clínico é raro e deve ser feito o diagnóstico diferencial com outras patologias. A avaliação lavoratorial é normalmente caracterizada por grandes elevações da amilase sérica, isoamilase pancreática e lipase. O tratamento do quadro de pancreatite aguda durante a gravidez objetiva a redução de estímulos à secreção das enzimas pancreáticas. Diagnóstico precoce e identificação da etiologia aliada à escolha terapêutica adequada asseguram bom prognóstico materno e fetal. A interrupção da gravidez parece não interferir no prognóstico da doença. Objetivou-se, com a presente revisão, abordar aspectos relevantes da pancreatite em gestantes, tais como fisiopatologia, diagnóstico, terapêutica e prognóstico.

Pancreatitis is characterized by inflammation of pancreas, showing disruption of the cell membrane and tissue proteolysis, followed by the activation of cells of immune response. It is a broad clinical spectrum disease and presents varied etiologies. During pregnancy, it deserves importance due to the high morbidity and mortality that accompany it. The lithiasis of the bile is the main etiologic factor in the pathogenesis of acute pancreatitis during pregnancy, and the pregnant women may develop acute pancreatitis associated with hyperlipidemia. Clinical diagnosis is rare and differential diagnosis should be made with other pathologies. The laboratory evaluation is usually characterized by high elevations of serum amylase, pancreatic isoamilase and lipase. The treatment for acute pancreatitis during pregnancy aiming the reduction of stimuli to the secretion of pancreatic enzymes. Early diagnosis and identification of etiology allied to appropriate therapy choice assurance good maternal and fetal prognosis. The interruption of pregnancy does not appear to influence the prognosis of the disease. The objective of this review was to approach relevant aspects of pancreatitis during pregnancy, such as pathophysiology, diagnosis, therapeutics and prognosis.

Evaluation of the efficacy and reproducibility of cholangiopancreatography by magnetic resonance for detecting biliary complications following orthotopic liver transplantation / Estudo da eficácia e da reprodutibilidade da colangiopancreatografia por ressonância magnética na detecção das complicações biliares pós-transplantes hepáticos

PURPOSE: To evaluate the accuracy and reproducibility of magnetic resonance cholangiopancreatography (MRCP) in the detection of biliary complications in liver transplanted patients. METHODS: A study was conducted, with blinded review of 28 MRCP exams of 24 patients submitted to liver transplantation. The images were reviewed by two independent observers, at two different moments, regarding the degree of biliary tree visualization and the presence or absence of biliary complications. The MRCP results were compared, when negative, to at least 3 months of clinical and biochemical follow-up, and when positive, to the findings at surgery or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: The degree of intrahepatic biliary tree visualization was considered good or excellent in 78.6 percent and 82.1 percent of the exams by the two observers and visualization of the donor duct, recipient duct and biliary anastomosis was considered good or excellent in 100 percent of the exams, by both observers. Six biliary complications were detected (21.4 percent), all of them anastomotic strictures. Intra and interobserver agreement were substantial or almost perfect (kappa k values of 0.611 to 0.804) for the visualization of the biliary tree and almost perfect (k values of 0.900 to 1.000) for the detection of biliary complications. MRCP achieved 100 percent sensitivity, 95.45 percent specificity, 85.7 percent positive predictive value and 100 percent negative predictive value for the detection of biliary complications. CONCLUSIONS: MRCP is an accurate examination for the detection of biliary complications after orthotopic liver transplantation and it is a highly reproducible method in the evaluation of the biliary tree of liver transplanted patients.

OBJETIVO: Medir a acurácia e reprodutibilidade da colangiopancreatografia por ressonância magnética (CPRM) na avaliação da visibilização de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos. MÉTODOS: Realizado estudo retrospectivo de 28 exames de CPRM de 24 pacientes submetidos a transplantes hepáticos. Os exames foram interpretados por dois observadores independentes, em dois momentos distintos, quanto ao grau de visibilização das estruturas estudadas e quanto à presença ou ausência de alterações nas vias biliares. Os resultados da CPRM foram comparados, nos casos de CPRM negativa, à evolução clínico-laboratorial por pelo menos 3 meses e, nos casos de CPRM alterada, aos achados de colangiopancreatografia retrógrada endoscópica (CPRE) e cirurgia, quando indicados. RESULTADOS: A visibilização das vias biliares intra-hepáticas foi considerada boa ou excelente em 78,6 por cento e 82,1 por cento dos exames pelos dois observadores. A visibilização da via biliar extra-hepática do doador e do receptor, bem como da anastomose biliar, foi considerada boa ou excelente em 100 por cento dos casos por ambos os observadores. Foram detectadas seis complicações biliares (21,4 por cento dos casos), todas elas estenoses anastomóticas. A concordância intra e intra-observador foi substancial ou quase perfeita (índices de kappa- k de 0,611 a 0,804) para a visualização das estruturas estudadas e quase perfeita (k de 0,900 a 1,000) para a detecção das complicações biliares. A CPRM apresentou sensibilidade de 100 por cento, especificidade de 95,45 por cento, valor preditivo positivo de 85,7 por cento e valor preditivo negativo de 100 por cento para a detecção de complicações biliares. CONCLUSÕES: A colangiopancreatografia por ressonância magnética (CPRM) é um exame acurado para a detecção de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos por CPRM. Este exame configura-se como um método eficiente ...

Tratamento endoscópico das lesões biliares / Endoscopic treatment of the biliary injuries

As técnicas cirúrgicas convencionais ofertam uma apropriada condição de cura na maioria dos pacientes com estreitamento biliar benigno. Nesta condição, no entanto, o reparo cirúrgico está associado com recorrência tardia da re-estenose em 10 por cento a 30 por cento dos pacientes. Neste contexto, os avanços tecnológicos na endoscopia terapêutica promoveram a possibilidade alternativa do tratamento efetivo destas obstruções benignas. Considerações em relação ao tempo de reospitalização e de procedimentos devem ser averiguados em detalhes e ponderados em relação á cirurgia. Estenoses malignas estão relacionadas á colangite, icterícia e dor e, consequentemente, com as alterações sistêmicas relacionadas com a sepsis biliar. A conduta endoscópica cria uma derivação do suco biliar para o duodeno, sendo uma verdadeira derivação biliodigestiva endoscópica e utilizando-se próteses plásticas ou metálicas. O propósito desta revisão é ofertar aos leitores a eficácia do tratamento endoscópico na estenose benigna e maligna biliopancreática.

Standard surgical techniques offer a good chance of cure forthe majority of patients affected by extrahepatic benign biliarystricture. Nevertheless, operative repair has a long-termrecurrence rate of stricture in 10 percent to 30 percent of patients. Advancesin endoscopic procedures have provided alternative options ofrelieving biliary obstructions, but prolonged length of treatmentand rehospitalization have to be considered if endoscopy isperformed. Malignant stenoses are an important factor determining cholangitis, jaundice and pain and it's each systemic consequences. The endoscopic approach intends to create a deviation of bile juice to duodenum by means of metal or plastic stents aiming a safe palliation. The purpose of this review is to show to the readerseffectiveness of endoscopic treatments of benign and malignat stenosis of the bile duct and pancreatic.

Spontaneous perforation of the extrahepatic biliary tract.

Spontaneous perforation of the extra-hepatic biliary tract presenting with pseudocyst is rare. We report the case of a two-month old infant who presented to us with increasing jaundice and progressive loss of weight. Ultrasonography, magnetic resonance cholangiopancreatography and hepatobiliary iminodiacetic acid scan revealed features of obstructed choledochal cyst. Laparotomy revealed a small, walled-offcollection of bile near the confluence of the cystic and common bile ducts. Distal obstruction was excluded and biliary tract drainage was successful in treating the infant.

Accuracy of MRCP Compared to ERCP in the Diagnosis of Bile Duct Disorders

AIM: To determine the accuracy of Magnetic Resonance Cholangiopancreatography compared to the gold standard Endoscopic Retrograde Cholangiopancreatography in the diagnosis of bile duct disorders at our institution. PATIENTS AND METHODS: 52 patients with suspected pancreatobiliary pathology were included in this prospective observational study. MRCP was performed in the 24-hour period prior to the ERCP. RESULTS: MRCP had sensitivity; specificity; positive and negative predictive values of 87; 80; 83.3and 84.2respectively for choledocholitiasis which correlates well with results obtained in other parts of the world. CONCLUSION: At our institution; MRCP has high diagnostic accuracy for bile duct calculi. Due to a small study population; results for other biliary pathology were inconclusive

Mucormycosis of the bile duct: a case report.

A case of isolated localised mucormycosis of the bile duct in an immuno-competent 54 year old female patient is described. Mucormycosis is rare in immuno-competent patients. Isolated localised mucormycosis of the bile duct has not yet been described in the literature.

Spontaneous biliary perforation in infancy and childhood: clues to diagnosis.

Spontaneous perforation of extrahepatic bile duct is rare. The cause is idiopathic once trauma and choledochal cyst are ruled out. The condition presents a diagnostic dilemma. Preoperative recognition is necessary as early surgical intervention gives excellent prognosis. We report clinical observations made in three cases with acute presentations. Diagnosis is to be suspected by the presence of jaundice after an initial anicteric period of good health with biliary ascites. This is confirmed by bilious abdominal paracentesis, signs of peritonitis and absent free gas on X ray. The constellation of these three findings was constant in three patients. The presented paper highlights the same as reliable clues to diagnosis.

A Case of Biliary Cast Syndrome after Cadaveric Liver Transplantation / 대한소화기학회지

We experienced one fatal case of biliary cast syndrome after cadaveric liver transplantation involving both intrahepatic ducts. A 58-year-old man underwent cadaveric liver transplantation because of hepatitis B virus related liver cirrhosis and concomitant hepatocellular carcinoma. Five weeks after the liver transplantation, postoperative course was complicated by development of acute cholangitis. Subsequent endoscopic retrograde cholangiography revealed diffuse intrahepatic bile duct strictures without filling defects. Percutaneous liver biopsy, which was done to exclude rejection, revealed biliary cast. Successful endoscopic removal was precluded due to its diffuse involvement. Because of the deterioration of patient's condition by refractory biliary obstruction and cholangitis, retransplantation from cadaveric donor was performed. Debridement of the biliary tree after graft removal yielded a near-complete cast of the intrahepatic ductal system. Biliary cast syndrome should be suspected when jaundice or cholangitis is associated with dilated ducts on abdominal imaging studies in cadaveric liver transplantation recipients. Initial therapeutic options include removal of biliary cast after endoscopic or percutaneous cholangiography. Although endoscopic retrieval of biliary cast by endoscopic retrograde cholangiopancreatography could be employed as a first-line management, other modalities such as endoscopic nasobiliary drainage, percutaneous transhepatic drainage, or retransplantation should be considered when complete removal is not feasible and the condition of the recipient deteriorates.

A Case of Infected Biloma due to Spontaneous Intrahepatic Biliary Rupture

A "biloma" is a loculated collection of bile located outside of the biliary tree. It can be caused by traumatic, iatrogenic or spontaneous rupture of the biliary tree. Prior reports have documented an association of biloma with abdominal trauma, surgery and other primary causes, but spontaneous bile leakage has rarely been reported. A spontaneous infected biloma, without any underlying disease, is a very rare finding. We recently diagnosed a spontaneous infected biloma by abdominal computed tomography and sonographically guided percutaneous aspiration. The patient was successfully managed with percutaneous drainage and intravenous antibiotics. We report here a case of infected biloma caused by spontaneous rupture of the intrahepatic duct, and review the relevant medical literature.