Bilhemia after trans-jugular intra-hepatic porto-systemic shunt and its management with biliary decompression.

Bilhemia or bile mixing with blood is a rare clinical problem. The clinical presentation is usually transient self-resolving hyperbilirubinemia, progressive and rapidly rising conjugated hyperbilirubinemia, or recurrent cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in diagnosis and management. Biliary decompression with endoscopic sphincterotomy is useful in treating these patients. If not recognized and treated in time, the condition can be fatal in a significant proportion of patients. This usually occurs after blunt or penetrating hepatic trauma due to a fistulous connection between the biliary radicle and portal or hepatic venous radical. Cases have been described due to iatrogenic trauma such as liver biopsy and percutaneous biliary drainage. However, the occurrence after trans-jugular intra-hepatic porto-systemic shunt (TIPS) is very rare. We report a case of bilhemia presenting as rapidly rising bilirubin after TIPS. The patient was managed successfully with ERCP and removal of a blood clot from the common bile duct.

The clinical significance of thickened gastric folds found on upper gastrointestinal series.

GOALS: To assess the impact of upper endoscopy and biopsy on the outcome of patients with isolated thickened gastric folds found on barium upper gastrointestinal series (UGIS). STUDY: A total of 8,325 consecutive UGIS reports were reviewed to identify 182 patients who were found to have isolated thickened gastric folds. Patients with other serious radiographic abnormalities were excluded. The 182 patients were studied by a systematic review of the esophagogastroduodenoscopy (EGD) findings, gastric biopsy results, and clinical outcome. RESULTS: The study included 96 men (52.7%) and 86 women (47.3%) who had isolated thickened gastric folds on the UGIS. Seventy-four patients underwent EGD; 108 patients did not. The two groups were similar in demographic and clinical features. The EGD results were normal, 18 (24.3%); thick gastric folds, 12 (16.2%); hiatal hernia, 12 (16.2%); erythema/inflammation, 11 (14.9%); erosions, 8 (10.8%); portal gastropathy, 3 (4.1%); and gastric ulcer, 1 (1.4%). Forty-eight of the 74 EGD patients had a gastric biopsy. The findings were chronic active gastritis, 39 (81.3%); and chronic gastritis, 5 (10.4%). Evidence for H. pylori infection was present in 91.7% of the gastric biopsies. Outcome (mean follow-up, 28.5 months) was assessed in 49 patients in the EGD group and in 55 patients in the non-EGD group. There were no cases of serious or new UGI problems in either group. CONCLUSIONS: Isolated thickened gastric folds found on UGIS are frequently associated with H. pylori infection. Performing endoscopy and biopsy did not appear to alter the outcome in these patients.