Intraductal Ultrasonography without Radiocontrast Cholangiogram in Patients with Extrahepatic Biliary Disease

BACKGROUND/AIMS: Intraductal ultrasonography (IDUS) has been performed as an adjunct to endoscopic retrograde cholangiography (ERC) during radiocontrast cholangiography (RC). Radiation exposure during RC poses a health risk to both patients and examiners. We evaluated the feasibility of IDUS without RC in various extrahepatic biliary diseases. METHODS: IDUS was performed with the insertion of an IDUS probe from the papilla of Vater to the confluent portion of the common hepatic duct without fluoroscopy. The technical success rate and procedure-related complications were evaluated retrospectively. RESULTS: Wire-guided IDUS without RC was performed in 105 patients. The mean age was 66.5 years, and 50 (47.6%) were male. The IDUS diagnoses included choledocholithiasis (73, 69.5%), benign biliary stricture (11, 10.5%), choledocholithiasis with biliary pancreatitis (9, 8.6%), bile duct cancer (5, 4.8%), pancreatic cancer (1, 0.9%), and others (6, 5.7%). After IDUS, 66 (62.8%) underwent stone removal, 19 (18.1%) underwent biliary drainage, and 7 (6.6%) underwent brush cytology and biopsy. No significant complications such as perforation or severe pancreatitis occurred. CONCLUSIONS: IDUS without RC was a feasible and safe approach in patients with various extrahepatic biliary diseases. We anticipate a potentially important role of IDUS in various ERC procedures because it lacks the hazards of RC.

Role of Balloon-Sheathed Intraductal Ultrasonography for Patients with Extensive Pneumobilia

Intraductal ultrasonography (IDUS) is one of the most useful diagnostic tools for various extrahepatic biliary diseases. However, conventional IDUS has some limitations in providing accurate cross-sectional imaging of the bile duct in patients with extensive pneumobilia. Using a balloon-sheathed catheter, the US system (balloon-sheathed IDUS) can overcome these limitations. Sixteen patients underwent balloon-sheathed IDUS during endoscopic retrograde cholangiography. The balloon-sheathed IDUS was inserted via a transpapillary route when visualization of the bile duct with conventional IDUS was distorted by extensive pneumobilia. The patient group had a mean age of 65.5 years, and 56.3% (9/16) were male. The balloon-sheathed IDUS permitted successful visualization of the bile duct in all patients, regardless of the extent of pneumobilia. Using this system, remnant common bile duct stones were detected in five patients (31.3%), and cholangiocarcinoma was detected in one patient (6.3%). The balloon-sheath IDUS aided in stone sweeping. No significant complications, including bleeding, perforation, or pancreatitis, occurred in any of the patients. The balloon-sheathed catheter US system was useful and safe for biliary IDUS in patients with extensive pneumobilia.

Right upper quadrant pain with normal hepatobiliary ultrasound: can hepatobiliary scintigraphy define the cause?

The objective of this study was to assess the value of hepatobiliary scintigraphy [HS] for the diagnosis of right upper quadrant [RUQ] abdominal pain in patients with normal hepatobiliary ultrasound [HU]. This is an observational study with a retrospective analysis of data from March 2008 to August 2010. We reviewed the HS results of 30 patients, aged 29-69 years [average 45.8 years]; 12 male and 18 female patients. Patient selection to perform the HS was RUQ abdominal pain, suspected hepatobiliary disorder, and negative HU. All patients had gone through the standard procedure of HS. Based on predefined interpretation criteria, HS results were divided into 2 patterns: Normal [n=8, 25.8%] and abnormal [n=22, 73%]: 18 patients [81.8%] having early gallbladder [GB] and common bile duct visualization, and delayed transit to small bowel [SB], which can be seen only after a fatty meal with normal or abnormal GB ejection fraction [GBEF] pattern characteristic of Oddi's sphincter dyskinesia. The remaining 4 patients [8.18%] had acalculous cholycystitis pattern: Delayed GB visualization with activity appearing in SB before GB. HS with fatty meal stimulation and GBEF estimation seems to be a reliable test, which may reveal a biliary cause in more than 70% of patients with RUQ abdominal pain and normal HU. Normal results exclude functional biliary cause. The decision for invasive or noninvasive therapeutic approach may depend on the results of HS

Selective Embolization for Post-Endoscopic Sphincterotomy Bleeding: Technical Aspects and Clinical Efficacy

OBJECTIVE: The objective of this study was to evaluate the technical aspects and clinical efficacy of selective embolization for post-endoscopic sphincterotomy bleeding. MATERIALS AND METHODS: We reviewed the records of 10 patients (3%; M:F = 6:4; mean age, 63.3 years) that underwent selective embolization for post-endoscopic sphincterotomy bleeding among 344 patients who received arteriography for nonvariceal upper gastrointestinal bleeding from 2000 to 2009. We analyzed the endoscopic procedure, onset of bleeding, underlying clinical condition, angiographic findings, interventional procedure, and outcomes in these patients. RESULTS: Among the 12 bleeding branches, primary success of hemostasis was achieved in 10 bleeding branches (83%). Secondary success occurred in two additional bleeding branches (100%) after repeated embolization. In 10 patients, post-endoscopic sphincterotomy bleedings were detected during the endoscopic procedure (n = 2, 20%) or later (n = 8, 80%), and the delay was from one to eight days (mean, 2.9 days; +/- 2.3). Coagulopathy was observed in three patients. Eight patients had a single bleeding branch, whereas two patients had two branches. On the selective arteriography, bleeding branches originated from the posterior pancreaticoduodenal artery (n = 8, 67%) and anterior pancreaticoduodenal artery (n = 4, 33%), respectively. Superselection was achieved in four branches and the embolization was performed with n-butyl cyanoacrylate. The eight branches were embolized by combined use of coil, n-butyl cyanoacrylate, or Gelfoam. After the last embolization, there was no rebleeding or complication related to embolization. CONCLUSION: Selective embolization is technically feasible and an effective procedure for post-endoscopic sphincterotomy bleeding. In addition, the posterior pancreaticoduodenal artery is the main origin of the causative vessels of post-endoscopic sphincterotomy bleeding.

Role of magnetic resonance cholangiopancreatography in the evaluation of biliary disease

Magnetic resonace cholangiopancreatography [MRCP] was introduced in 1991, as a non-invasive method of imaging the biliary tree. Although endoscopic cholongiopancreatography [ERCP] has been the mainstay for diagnosing and treating pancreatico-biliary disease, complications such as pancreatitis, cholangitis, haemorrhage and duodenal perforation have limited its use as a routine diagnostic test. Although ERCP is still the standard of reference for imaging the pancreatico-biliary system, MRCP is the examination of choice in a setting where ERCP is difficult or impossible. It is useful in cases with severe biliary obstruction to evaluate the ducts proximal to the obstruction. MRCP has specific advantages over ERCP as it is non-invasive, cheaper, uses no radiation, requires no anaesthesia and is less operator dependent. When combined with conventional T1- and T2-weighted sequences, it allows detection of extraductal disease. The technology is still evolving to make the MRCP examination faster, sharper and with higher spatial resolution

Biliary ascariasis in the indian subcontinent: a study of 42 cases

History of ascariasis is known to stretch back many centuries. One quarter of the world's population is known to be infected by ascariasis. It is endemic in various parts of the Indian subcontinent and the gangetic plain of West Bengal is one of them. We aimed to study the various types of clinical presentations, complications and different diagnostic tools and to assess various options for the management of biliary ascariasis. Forty-two cases of hepatobiliary ascariasis were studied over a period of 3 years. All the patients were adults aged between 20 and 50 years and all but two were admitted with acute upper abdominal pain. In this study, biliary ascariasis was found to be more common in females, 73.8% [31 patients]. The most common presentation was upper abdominal pain in 95.2% of the patients [40 patients]. Complications observed were obstructive jaundice in 28.56% [12 patients], cholangitis in 16.7% [seven patients], acute pancreatitis in 2.4% [one patient] and hepatic abscess in 2.4% [one patient]. History of worm emesis was present in 38.1% [16 patients]. History of previous cholecystectomy was present in 16.7% [seven patients] and endoscopic sphincterotomy in 4.8% [two patients]. Ultrasound was the diagnostic tool of choice with 100% results. Conservative management was successful in 83.3% [35 patients]. During follow-up, worm reinvasion of the biliary system occurred in 7.1% [three patients]. In endemic countries, ascariasis should be suspected in patients with biliary disease, especially if a cholecystectomy or sphincterotomy has been performed in the past. Most of the patients respond to conservative management

Biliary ascariasis: the value of ultrasound in the diagnosis and management

Conventional methods of radiographic examination are often unsatisfactory for identifying worms in the biliary tract. Ultrasonography is a non-invasive, quick and safe procedure known to have diagnostic accuracy. We studied the ultrasonographic appearances of biliary ascariasis and the role of ultrasonography in diagnosis and management. In a prospective 5-year study, a sonographic diagnosis of biliary ascariasis was made on 46 Yemeni patients. The diagnosis was based mainly on sonographic appearances supported by clinical and laboratory results and proved by outcome of either surgical or medical management or spontaneous exit of worms. Follow-up ultrasound was performed for all patients to confirm the diagnosis and to monitor management. Parasites were present in the dilated main bile duct in 23 patients, in the gallbladder in 12 patients, in the intrahepatic ducts in 6 patients, in the main pancreatic duct in 4 patients and as an intrahepatic abscess in one patient. The characteristic appearance of Ascaris lumbricoides was as single or multiple echogenic nonshadowing linear or curved strips with or without echoic tubular central lines that represent the digestive tracts of the worm. A spaghetti-like appearance was seen in 9 patients and amorphous fragments were seen in 2 patients. Sixteen patients underwent surgery, 20 patients were treated medically [including spontaneous exit of the worm in 7 patients without treatment] and in 10 patients worms were extracted by endoscopic retrograde cholangiopancreatography. Follow-up ultrasound was found to be effective in confirming the diagnosis and monitoring management

Ultrasonographic patterns of hepatobiliary mass lesions.

The study deals with an analysis of ultrasonographic (USG) patterns in 100 consecutive patients with hepatobiliary mass lesions. Amoebic liver abscess, carcinoma (CA) gall bladder and secondaries in liver comprised nearly 70% of cases. USG appearances in liver abscess, hepatoma, secondaries in liver and CA gall bladder were variable, but were characteristic in hydatid disease and congenital polycystic disease. Two patients with cholangiocarcinoma revealed dilated biliary channels with an intraluminal mass in common bile duct.