Fístula biliopleurobronquial: reporte de un caso / Bronchobiliary fistula: Report of a case

La fístula biliopleurobronquial (FBB) es una comunicación anormal entre la vía biliar y el árbol bronquial. Es una condición infrecuente, generalmente secundaria a un proceso infeccioso local o a un evento traumático. La bilioptisis es patognomónica. Presentamos el caso de una mujer de 37 años con historia de cirrosis biliar secundaria, en lista para trasplante hepático, con múltiples episodios de colangitis previos y usuaria de derivación biliar externa, quien curso con bilioptisis y mediante gammagrafía HIDA con SPECT se confirmó fistula biliopleurobronquial. Éste caso se resolvió con derivación percutánea de la vía biliar

Bronchobiliary fistula (BBF) is an abnormal communication between the biliary tract and the bronchial tree. Is an infrequent condition, usually secondary to a local infectious process or a traumatic event. Bilioptisis is pathognomonic. We present the case of a 37 year old woman with secondary biliary cirrhosis, in list for liver transplantation, with several episodes of cholangitis and carrier of external biliary diverivation, who presented bilioptisis and HIDA scintigraphy with SPECT confirmed BBF. This case was resolved with percutaneous derivation of the biliary tract

Cholangiohydatidosis: an Infrequent Cause of Obstructive Jaundice and Acute Cholangitis

ABSTRACT Background. One of the evolutionary complications of hepatic echinococcosis (HE) is cholangiohydatidosis, a rare cause of obstructive jaundice and cholangitis. The aim of this study was to describe the results of surgical treatment on a group of patients with cholangiohydatidosis and secondary cholangitis in terms of post-operative morbidity (POM). Material and method. Case series of patients operated on for cholangiohydatidosis and cholangitis in the Department at Surgery of the Universidad de La Frontera and the Clínica Mayor in Temuco, Chile between 2004 and 2014. The minimum follow-up time was six months. The principal outcome variable was the development of POM. Other variables of interest were age, sex, cyst diameter, hematocrit, leukocytes, total bilirubin, alkaline phosphatase and transaminases, type of surgery, existence of concomitant evolutionary complications in the cyst, length of hospital stay, need for surgical re-intervention and mortality. Descriptive statistics were calculated. Results. A total of 20 patients were studied characterized by a median age of 53 years, 50.0% female and 20.0% having two or more cysts with a mean diameter of 13.3 ± 6.3 cm. A median hospital stay of six days and follow-up of 34 months was recorded. POM was 30.0%, re-intervention rate was 10.0% and mortality rate was 5.0%. Conclusion. Cholangiohydatidosis is a rare cause of obstructive jaundice and cholangitis associated with significant rates of POM and mortality.(AU)

Seguimiento de pacientes con atresia biliar: cirugía tardía y desarrollo de lagunas biliares / Follow up for a cohort of patients with biliary atresia: late surgery and development of biliary cysts

Las dilataciones quísticas de las vías biliares, conocidas como lagunas biliares, se han descrito en el seguimiento de los pacientes sometidos a portoenterostomía o cirugía de Kasai por atresia de las vías biliares (AVB). Su aparición se ha asociado con el desarrollo de colangitis y consecuentemente a un peor pronóstico. OBJETIVO: Describir las características clínicas y pronóstico de pacientes con AVB, sometidos a cirugía de Kasai, con énfasis en aquellos que desarrollaron lagunas biliares. PACIENTES Y MÉTODO: Estudio retrospectivo de pacientes sometidos a portoenterostomía de Kasai por AVB durante los años 2008 a 2016. Se tabuló la información demográfica y variables asociadas a la portoenterostomía de Kasai, trasplante hepático, lagunas o quistes biliares y episodios de colangitis. Se crearon curvas de Kaplan Meier y comparación mediante el test de Log Rank para evaluar sobrevida global, libre de colangitis y con hígado nativo, considerando un valor p como significativo. RESULTADOS: Se analizó el seguimiento de 13 pacientes. El tiempo promedio de realización del Kasai fue a los 85 meses (rango 42-193, DS 40,3), seis pacientes (46%) fueron sometidos a cirugía de Kasai después de los 90 días de vida por derivación tardía. Cuatro (31%) desarrollaron lagunas biliares múltiples, todos presentaron episodios de colangitis. La sobrevida libre de colangitis fue significativamente menor para los portadores de lagunas biliares. Nueve pacientes (69%) recibieron un trasplante hepático, en promedio a los 16 meses de edad (rango 6-40, DS 12,1), en 3 de ellos la causa fue colangitis recurrente. No se encontraron diferencias significativas en la sobrevida con hígado nativo ni en sobrevida global entre portadores y no portadores de lagunas biliares. CONCLUSIONES: En esta cohorte, la incidencia de lagunas biliares luego de la portoenterostomía es similar a la descrita en la literatura. Los resultados concuerdan con la relación propuesta entre ellas y el desarrollo de colangitis. En los pacientes de nuestra serie, el diagnóstico y derivación de AVB fue realizado tardíamente, determinando un peor pronóstico.

Since the introduction of Kasai’s hepatic portoenterostomy, the prognosis of patients with biliary atresia has improved. The presence of intrahepatic biliary cysts or bile lakes has been reported in some patients after the intervention. Bile lakes have been related to cholangitis and a poor outcome. OBJECTIVE: To describe the clinical features and prognosis of patients with biliary atresia after Kasai portoenterostomy, with special emphasis in those who developed biliary cysts. PATIENTS AND METHOD: Data from a retrospective cohort of 13 patients with biliary atresia with a Kasai portoenterostomy from 2008 to 2016 was analyzed. Demographic variables associated to Kasai portoenterostomy, hepatic transplant, biliary cysts and colangitis episodes were tabulated. Kaplan Meir and Log Rank test were used to evaluate colangitis-free and native liver survival. RESULTS: The mean age at Kasai was 85 months (SD 40.3, 42-193 months), six patients (46%) had a Kasai operation after 90 days of life. Four patients (31%) developed multiple biliary cysts; all of them had at least one episode of cholangitis. Cholangitis-free survival was significantly lower for those who developed bile lakes. Nine patients (69%) underwent liver transplant, 3 of them because of recurrent cholangitis. There were no differences in global survival or native liver survival between patients with or without biliary cysts. CONCLUSIONS: The incidence of biliary cysts after Kasai portoenterostomy in this series is similar to the reported. The results are consistent with the relationship proposed between the development of biliary cysts and cholangitis. Our patients, some already derived for evaluation and liver transplantation, underwent Kasai operation at an advanced age, which determines a poor prognosis.

Colangiopancreatografía retrógrada endoscópica en gestante de 35, 4 semanas con colangitis por litiasis coledociana / Endoscopic retrograde cholangiopancreatography in 35.4-weeks pregnant women with cholangitis caused by choledocholithiasis

La colangitis aguda puede definirse como el síndrome caracterizado por signos y síntomas de infección sistémica con origen en el árbol biliar. Se produce por la presencia de bacterias en la bilis junto a un aumento de la presión intrabiliar por una obstrucción, siendo la coledocolitiasis la causa más frecuente. El tratamiento de esta entidad se basa en la combinación del drenaje biliar y la administración de antibióticos. Esta entidad infrecuente en gestantes, aparece en una gestante con 35,4 semanas de gestación, que llega a la institución de salud por fiebre referida, vómitos, dolor epigástrico e íctero, se le realiza ultrasonido abdominal constatando dilatación de vía biliar y leucograma alterado con predominio de los segmentados, con stab y gránulos tóxicos; lo cual permite realizar diagnóstico de colangitis. Se realizó una colangiopancreatografía retrógrada endoscópica mediante la técnica convencional, con la paciente en decúbito lateral izquierdo oblicuo. Se utilizó arco en C y las imágenes fueron interpretadas por el endoscopista, con un mínimo de radiación. Se realizó canulación selectiva de la vía biliar y opacificó, observando dilatación de las vías biliares intrahepáticas, colédoco dilatado de 15mm, en cuyo interior se observa defecto de lleno ovoide. Se realizó esfinterotomía amplia y se extrajo cálculo pardo de 1cm de diámetro y varios litios pequeños, acompañados de abundante contenido biliar y pus blanquecino. Posterior a la colangiopancreatografía retrógrada endoscópica la paciente evoluciona de forma satisfactoria.

Acute cholangitis may be defined as the syndrome characterized by signs and symptoms of systemic infection originated in the biliary tree). The presence of bacteria in the bile together with the increment of the intra-biliary pressure due to an obstruction produces it; choledocholithiasis is the most frequent cause. The treatment of this entity is based on the combination of the biliary drainage and antibiotics administration. This entity, infrequent in pregnant women, appears in a pregnant woman with 35.4 weeks of pregnancy, who visited the health institution referring fever, vomits, epigastric pain and jaundice. An abdominal ultrasound showed biliary way dilatation and the leukogram was altered with predominance of the segmented ones, stab and toxic granules, allowing arriving to the diagnosis of cholangitis. An endoscopic retrograde cholangiopancreatography was carried out using the conventional technique, with the patient in oblique right lateral decubitus. An arc in C was used and the endoscopist interpreted the obtained images; with a minimum radiation, a selective cannulation of the biliary way was made and made it opaque, observing dilatation of the intra-hepatic biliary ways, dilated common bile duct of 15 cm. Inside it, it was observed an ovoid defect of filling; a wide sphincterotomy was developed and a brown calculus of 1 cm of diameter and several little ones, accompanied by abundant biliary substance and whitish pus were extracted. After the endoscopic retrograde cholangiopancreatography the patient had a satisfactory evolution.

Percutaneous Unilateral Biliary Metallic Stent Placement in Patients with Malignant Obstruction of the Biliary Hila and Contralateral Portal Vein Steno-Occlusion

OBJECTIVE: To investigate the outcomes of percutaneous unilateral metallic stent placement in patients with a malignant obstruction of the biliary hila and a contralateral portal vein steno-occlusion. MATERIALS AND METHODS: Sixty patients with a malignant hilar obstruction and unilobar portal vein steno-occlusion caused by tumor invasion or preoperative portal vein embolization were enrolled in this retrospective study from October 2010 to October 2013. All patients were treated with percutaneous placement of a biliary metallic stent, including expanded polytetrafluoroethylene (ePTFE)-covered stents in 27 patients and uncovered stents in 33 patients. RESULTS: A total of 70 stents were successfully placed in 60 patients. Procedural-related minor complications, including self-limiting hemobilia (n = 2) and cholangitis (n = 4) occurred in six (10%) patients. Acute cholecystitis occurred in two patients. Successful internal drainage was achieved in 54 (90%) of the 60 patients. According to a Kaplan-Meier analysis, median survival time was 210 days (95% confidence interval [CI], 135-284 days), and median stent patency time was 133 days (95% CI, 94-171 days). No significant difference in stent patency was observed between covered and uncovered stents (p = 0.646). Stent dysfunction occurred in 16 (29.6%) of 54 patients after a mean of 159 days (range, 65-321 days). CONCLUSION: Unilateral placement of ePTFE-covered and uncovered stents in the hepatic lobe with a patent portal vein is a safe and effective method for palliative treatment of patients with a contralateral portal vein steno-occlusion caused by an advanced hilar malignancy or portal vein embolization. No significant difference in stent patency was detected between covered and uncovered metallic stents.

A Comparison of Preoperative Biliary Drainage Methods for Perihilar Cholangiocarcinoma: Endoscopic versus Percutaneous Transhepatic Biliary Drainage

BACKGROUND/AIMS: Controversy remains over the optimal approach to preoperative biliary drainage in patients with resectable perihilar cholangiocarcinoma. We compared the clinical outcomes of endoscopic biliary drainage (EBD) with those of percutaneous transhepatic biliary drainage (PTBD) in patients undergoing preoperative biliary drainage for perihilar cholangiocarcinoma. METHODS: A total of 106 consecutive patients who underwent biliary drainage before surgical treatment were divided into two groups: the PTBD group (n=62) and the EBD group (n=44). RESULTS: Successful drainage on the first attempt was achieved in 36 of 62 patients (58.1%) with PTBD, and in 25 of 44 patients (56.8%) with EBD. There were no significant differences in predrainage patient demographics and decompression periods between the two groups. Procedure-related complications, especially cholangitis and pancreatitis, were significantly more frequent in the EBD group than the PTBD group (PTBD vs EBD: 22.6% vs 54.5%, p<0.001). Two patients (3.8%) in the PTBD group experienced catheter tract implantation metastasis after curative resection during the follow-up period. CONCLUSIONS: EBD was associated with a higher risk of procedure-related complications than PTBD. These complications were managed properly without severe morbidity; however, in the PTBD group, there were two cases of cancer dissemination along the catheter tract.

Acute Obstructive Cholangitis Complicated by Tumor Migration after Transarterial Chemoembolization: A Case Report and Literature Review / 대한소화기학회지

Intraductal tumor invasion of hepatocellular carcinoma (HCC) is considered rare. Transarterial chemoembolization (TACE) is effective for tumor thrombus of HCC in the bile duct. However, a few cases of obstructive jaundice caused by migration of a tumor fragment after TACE have recently been reported. The aim of this study was to identify factors that affect tumor migration after TACE. At this writing, a review of the medical literature disclosed seven reported cases of biliary obstruction caused by migration of a necrotic tumor cast after TACE. We, herein, report on an additional case of acute obstructive cholangitis complicated by migration of a necrotic tumor cast after TACE for intrabile duct invasion of HCC, in a 71-year-old man. The tumor cast in the common bile duct was removed successfully using a basket during ERCP and was pathologically confirmed to be a completely necrotic fragment of HCC. The patient's symptoms showed dramatic improvement. In summary, physicians should be aware of acute obstructive cholangitis complicated by tumor migration in a patient undergoing TACE. We suggest that an intrabile duct invasion would be a major predisposing factor of tumor migration after TACE and drainage procedures such as ERCP or percutaneous transbiliary drainage could be effective treatment modalities in these patients.

Endoscopic Retrograde Cholangiopancreatography in Patients with Previous Acute Coronary Syndrome

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is considered a high-risk procedure in patients with previous acute coronary syndrome (ACS); however, clinical studies are rare in the literature. The aim of this study was to investigate the safety and efficacy of ERCP in patients with previous ACS. METHODS: We retrospectively reviewed the medical records of patients with previous ACS who underwent ERCP between January 2007 and August 2012. The clinical characteristics, ERCP diagnoses, treatment results, and complications were analyzed. RESULTS: Fifty patients underwent ERCP an average of 41.6 months after ACS. The most common indication for ERCP was calculous cholangitis. After deep biliary cannulation, endoscopic sphincterotomy, biliary stone removal and endoscopic biliary drainage were successfully performed. Immediate postsphincterotomy bleeding occurred in seven patients, which was successfully controlled using endoscopic therapy. Elevation of cardiac troponin I levels were observed in three patients (6%) before ERCP, and all of these patients were diagnosed with pancreatobiliary disease combined with recurrent ACS, which was treated with coronary artery stent insertion (n=2) and balloon angioplasty (n=1). CONCLUSIONS: Therapeutic ERCP is effective and safe in patients with previous ACS. Cardiac troponin I elevation should be considered a warning sign for recurrent ACS in patients who undergo ERCP.

Colangitis secundaria a espirales metálicos emigrados al conducto biliar / [Cholangitis secondary to migrated metallic coils in the common bile duct].

Biliary obstructions are infrequently caused by foreign bodies. We present an unusual case of angiographically placed metallic coils into the intrahepatic arteries to provide hemostasis, that subsequently eroded into the common bile duct leading to obstructive jaundice and cholangitis a year later. In patients with history of invasive procedures, the possibility of foreign body migration into the common bile duct should always be considered in the differential diagnosis of obstructive jaundice and cholangitis.

A Case of Afferent Loop Syndrome with Acute Cholangitis Developed after Percutaneous Transhepatic Cholangioscopic Lithotripsy for Treatment of Choledocholithiasis in a Patient Who Underwent Billroth II Gastrectomy / 대한소화기학회지

Afferent loop syndrome is a rare complication which can occur in patients with Billroth II gastrectomy. Bile and pancreatic juice is congested at afferent loop in the syndrome. This syndrome can progress rapidly to necrosis, perforation, or severe sepsis, and therefore early diagnosis and swift surgical intervention is important. But, cases of endoscopic or percutaneous transhepatic drainage have been reported when surgical management was inappropriate to proceed. We report a case of afferent loop syndrome accompanying acute cholangitis developed after percutaneous transhepatic cholangioscopic lithotripsy for the retrieval of common bile duct stone in a patient who underwent Billroth II gastrectomy due to early gastric cancer. There was no other organic cause. We treated afferent loop syndrome successfully by performing balloon dilation of afferent loop outlet.

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).

Quistes de colédoco en adultos / Choledochal cysts in adults

Introducción: Los quistes de colédoco en adulto son muy raros ya que la mayoría se diagnostica antes de los 10 años de edad. Los síntomas más frecuentes son dolor abdominal e ictericia, principalmente en mujeres. El objetivo de esta investigación fue informar la experiencia en el manejo de quistes de colédoco en adultos en un hospital de tercer nivel. Material y métodos: Estudio retrospectivo, descriptivo, observacional y transversal de la evolución posoperatoria de pacientes adultos con diagnóstico de quistes de colédoco tratados en un servicio de cirugía general en un periodo de 17 años. Resultados: Fueron en total 23 pacientes, de los cuales 16 fueron mujeres, con una mediana de edad de 26 años. Los síntomas principales fueron dolor abdominal (87 %) e ictericia (57 %). Solo cuatro pacientes (17 %) tuvieron además de estos síntomas tumor abdominal. El método diagnóstico más utilizado fue ultrasonido (100 %) seguido de colangiografía endoscópica (78 %) y tomografía computarizada de abdomen (74 %). De acuerdo con la clasificación de Todani, el tipo de quiste fue I en 17 pacientes, II en dos pacientes, III en tres pacientes y IV-A en un paciente. Todos fueron intervenidos quirúrgicamente, a 18 se les realizó resección del quiste y hepatoyeyuno anastomosis, a dos resección del quiste y a tres esfinteroplastia transduodenal. Hubo complicaciones posoperatorias en siete pacientes (35 %) y no hubo mortalidad operatoria. Solo en uno se informó colangiocarcinoma. Conclusiones: La cirugía de elección para el manejo de los quistes de colédoco es la resección del mismo, con morbilidad y mortalidad aceptables.

BACKGROUND: Choledochal cysts are usually diagnosed during childhood. They mainly affect females. Abdominal pain and jaundice are the two most common symptoms. Our objective was to report the experience of a third-level referral center in the management of choledochal cysts in adults. METHODS: We performed a 17-year retrospective review of patients with choledochal cysts who underwent surgical interventions in a gastrointestinal surgery department. RESULTS: There were 23 patients with a median age of 26 years; 16 were females. The most frequent symptoms were abdominal pain and jaundice. Only four patients had an abdominal mass. The most frequently used diagnostic studies were abdominal sonography and endoscopic retrograde cholangiopancreatography. According to the classification of Todani, most cysts were type I and were found in 17 patients, two patients had type II, three patients had type III (choledocele) and one patient had type IVA. Eighteen patients underwent complete removal of the cyst with a concomitant hepatic-jejunostomy, three patients had transduodenal sphincteroplasty and two patients had only cystectomy. Seven patients developed postoperative complications, representing a morbidity rate of 35%. None of the patients died during the first 30 postoperative days. Cholangiocarcinoma was found in the resected specimen in only one case. CONCLUSIONS: The surgery of choice for choledochal cysts in the adult is hepatojejunostomy, which has a low surgical morbidity and mortality.

Acute Obstructive Cholangitis after Transarterial Chemoembolization: the Effect of Percutaneous Transhepatic Removal of Tumor Fragment

Acute obstructive cholangitis due to the migration of necrotized tumor fragment is a rare complication occurring after a transarterial chemoembolization. The percutaneous tumor removal procedure following percutaneous transhepatic biliary drainage is an appropriate treatment over endoscopic removal for the relief of acute cholangitis in this case. Following this serial management, no invasive hepatocellular carcinoma of the bile duct recurred after two years of follow-up.

Resultados del drenaje endoscópico de la vía biliar en el tratamiento de la colangitis aguda / Endoscopic drainage of biliary tract in acute cholangitis

La exploración quirúrgica de la vía biliar seguida de la instalación de una sonda de Kehr ha sido por años el tratamiento de elección de la colangitis aguda en los servicios de urgencia de nuestro país. Actualmente el drenaje endoscópico de la vía biliar se ha situado como la modalidad de elección dada su menor morbimortalidad. El objetivo del presente estudio es mostrar y analizar los resultados de la colangiografía endoscópica retrógrada (CPER) en el Hospital Clínico Regional de Valdivia en el tratamiento de la colangitis aguda. Se realiza un estudio retrospectivo mediante revisión de fichas clínicas en base a protocolo tipo de los pacientes intervenidos vía endoscópica con diagnóstico de colangitis aguda, entre los años 2004 y 2006 en dicho centro. Los datos fueron analizados mediante una planilla Excel. La serie está constituida por 70 pacientes, de los cuales el 62,9 por ciento corresponden a sexo femenino. La edad promedio corresponde a 70,4 años. Un 34,3 por ciento de los pacientes fue intervenido dentro de las primeras 24 horas de hospitalización. El tiempo de hospitalización total presentó una mediana de 5 días (1-19). La mediana del postoperatorio correspondió a 3 días (1-17). Un 91,4 por ciento de los pacientes es intervenido con diagnóstico preoperatorio de colangitis aguda, lo que se confirma en la totalidad de la muestra durante el procedimiento. A un 95,7 por ciento de los pacientes se les efectuó ecografía previa. Tomografía computada (TC) se realizó en un 5,7 por ciento de los casos y Colangioresonancia en un paciente (1,4 por ciento). Un 95,1 por ciento y un 77,1 por ciento de los pacientes presentó vía biliar dilatada ecográficamente y durante CPER respectivamente. En un 85,7 por ciento se confirma la presencia de coledocolitiasis. En un 1,7 por ciento no se logra la descompresión total de la vía biliar en un primer intento. En todos los casos se realizó tratamiento antibiótico, cuya mediana fue 10 días (2-17). No hubo complicaciones...

Pancreatic calculus impacted at Ampulla of Vater causing severe cholangitis and septic shock.

Patients with chronic pancreatitis may have varied complications including common bile duct stenosis, cholangitis, pseudocyst or fistula formation and secondary biliary cirrhosis. Common bile duct obstruction due to disimpaction of a pancreatic calculus into the ampulla of Vater leading to severe cholangitis and septic shock is a rare phenomenon. We are reporting such a case here.

Ischemic stricture of Roux-en-Y intestinal loop and recurrent cholangitis.

The commonest complication of hepaticojejunostomy for the management of biliary strictures is recurrent cholangitis. We report a 54-year-old man who underwent choledochojejunostomy after choledochal cyst excision, and later developed ischemic stricture of the Roux-en-Y loop intestinal loop and recurrent cholangitis. The stricturous intestinal loop was excised with re-anastomosis with new Roux-en-Y loop, with uneventful recovery.

Fish Bone as a Nidus for Stone Formation in the Common Bile Duct: Report of Two Cases

We report two cases of common bile duct stone formed around a fish bone which migrated from the intestinal tract, along with their characteristic imaging findings. Two patients who had no history of previous operation were admitted because of cholangitis. Percutaneous transhepatic biliary drainage (PTBD) was performed and the cholangiogram showed filling defects with an unusually elongated shape in the common bile duct. After improvement of the cholangitic symptoms, the stones were removed through the PTBD tract under fluoroscopic guidance. A nidus consisting of a 1.5 cm sized fish bone was found in each stone removed.