Does periampullary diverticulum affect ERCP cannulation and post-procedure complications? an up-to-date meta-analysis.

Research conclusions differ on the impact of periampullary diverticulum (PAD) on endoscopic retrograde cholangiopancreatography (ERCP). An up-to-date meta-analysis evaluated the role of PAD in ERCP, especially in terms of cannulation failure and early complications. A comprehensive literature search was performed. All statistical analyses were carried out with the Review Manager 5.3 software. Horizontal lines represented a 95% confidence interval (CI) and the area of each square in forest plots. Twenty-six studies including 23 826 patients with or without PAD who underwent ERCP were evaluated. PAD was associated with an increase in the overall cannulation failure rate (RR=1.46, 95% CI: 1.27-1.67; p<.00001), but in the subgroup of studies performed post-2000, PAD was irrelevant to cannulation failure (RR=1.16, 95% CI: 0.96-1.41; p=0.12). In overall analyses, PAD was also associated with a high risk of ERCP-related pancreatitis (RR=1.32, 95% CI: 1.10-1.59; p=0.003), perforation (RR=1.73, 95% CI: 1.06-2.82; p=0.030), and bleeding (RR=1.48, 95% CI: 1.13-1.93; p=0.005). The presence of PAD increased the overall cannulation failure rate, but not the rate post-2000. PAD also affected the occurrence of early pancreatitis, perforation, and bleeding.

Limy bile syndrome presenting as acute acalculous cholecystitis.

A 35-year-old woman presented to the surgical clinic complaining of right hypochondrial pain for 4 days. Abdominal examination revealed tenderness on deep palpation in the right hypochonrdium, with no palpable organs or masses. The patient had repeated attacks of the same pain that mandated repeated admissions to the emergency hospital and treated conservatively. The white blood cell count was 13 000 cells/µL. Ultrasound examination of the abdomen showed thick-walled gall bladder, thick bile, with no visible stones and acalculous cholecystitis was the diagnosis. Decision done for laparoscopic cholecystectomy. After removal of the gall bladder and opening the bladder, a thick milky contents was found to fill the gall bladder with no stones. The diagnosis of limy bile syndrome then done. Histopathological examination of the gall bladder showed features of chronic cholecystitis with no malignancy. The patient discharged on the third postoperative day with no complications.

Pyogenic granuloma of the ampulla of Vater: unexpected cause of gastrointestinal bleeding.

We describe the case of a previously healthy 8-year-old girl presenting with a 1-year history of iron deficiency anemia. There was no report of hematemesis, abdominal pain or melena. Laboratory work-up excluded iron malabsorption as the underlying cause. Therefore, endoscopic evaluation was performed to exclude gastrointestinal blood loss, which revealed the presence of a 7 mm reddish lesion located within the ampulla of Vater. Capsule endoscopy excluded alternative diagnoses and concomitant lesions. Histopathological examination confirmed the diagnosis of pyogenic granuloma. The young age of the child and the benign nature of this lesion along with the absence of complications favored conservative management. Pyogenic granuloma is a benign vascular lesion that presents as a polypoid red mass. In the gastrointestinal tract, it is a rare condition and occurs more commonly in the elderly. The most common sites are the small intestine, esophagus, and colon, but they can occur throughout the entire gastrointestinal tract with a propensity to bleed that may cause iron deficiency anemia. In pediatric age patients, there are few reports of gastrointestinal pyogenic granulomas, most of which occur in the colon and rectum. Its identification and location in the ampulla of Vater is an exceptional finding.

Heterotopic chondroid tissue of the main bile duct mimicking Klatskin tumor: case report and review of the literature.

Heterotopic tissue in the bile duct is a very rare condition. There are a few case reports of heterotopic tissue including gastric and pancreatic cells. However, we could not find any data regarding heterotopic chondroid tissue obstructing the common bile duct in the literature. A 56-year-old woman was admitted to our hospital with complaints of progressive jaundice and pruritus. Laboratory test results were within the normal limits except bilirubin and alkaline phosphatase which were 10.8 mg/dL and 256 IU/L, respectively. Endoscopic retrograde cholangiography (ERCP) and computed tomography (CT) revealed a biliary stricture confined to the upper part of the common bile duct. The patient was operated as soon as the bilirubin level dropped below 5 mg/dL by percutaneous transhepatic cholangiography. Despite the lack of a precise confirmation, the patient was prepared for operation considering the possibility of a malignant biliary tumor since the radiographic mass findings together with hyperbilirubinemia were highly suggestive of malignancy. The patient underwent total extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy, and was discharged without any postoperative complications. Histologic examination of the bile duct and the nodule revealed the presence of a well-demarcated chondroid tissue within the subepithelial connective tissue. Herein, we presented the first case, to our knowledge, of heterotopic chondroid tissue of the common bile duct in the literature. It is a benign condition that should be considered in the differential diagnosis of stricture and mass-forming lesions of the bile duct.

Tubercular biliary hilar stricture: A rare case report.

Localized hepatic tuberculosis (TB) with or without bile duct involvement is a rare form of hepatobiliary tuberculosis; accounting for less than 1% of all tuberculous infections. We report an uncommon case of cholestatic jaundice with disseminated TB in an immunocompetent male who presented with simultaneous involvement of liver and biliary system.

The Usefulness of Cap-assisted Endoscopic Retrograde Cholangiopancreatography for Cannulation Complicated by a Periampullary Diverticulum.

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced therapeutic procedure to manage choledocholithiasis and pancreatobiliary malignancy. On occasion, ERCP failure is encountered due to difficulties in cannulation. We assessed the safety and feasibility of cap-assisted ERCP via analyzing cases in which cannulation was complicated by periampullary diverticulum. Between November 2013 and March 2014, ERCP procedures were performed in 346 patients in our tertiary medical center. Among the 73 patients who had a periampullary diverticulum, conventional ERCP failed in 5 patients due to hidden papilla (n=3) or use of tangential approach (n=2). As a rescue method, needle knife fistulotomy and selective biliary cannulation using cap-fitted forward-viewing endoscopy were successfully used in 4 patients without major complications. Based on our experience, cap-fitted forward-viewing endoscopy was relatively easy to measure the exact position of papilla and to perform biliary cannulation properly. Therefore, we recommend using cap-assisted ERCP by forward-viewing endoscopy as a useful and safe alternative to manage patients in whom cannulation is complicated by periampullary diverticulum.

Endoscopic Sphincterotomy for Gallbladder Muddy Stones or Sludge in Patients With Papillary Disease: A Retrospective Study.

BACKGROUND: The formation of gallbladder stones is associated with dysfunctional contraction and duodenal papilla diseases. However, endoscopic sphincterotomy can improve the contraction of the gallbladder and resolve duodenal papilla disease. AIM: The aim of the study was to assess the feasibility and effectiveness of endoscopic sphincterotomy in the treatment of muddy stones or sludge in the gallbladder during papillary disease. METHODS: The clinical data of 53 patients with gallbladder muddy stones or sludge undergoing endoscopic sphincterotomy were retrospectively analyzed. RESULTS: A total of 53 patients received successful endoscopic sphincterotomy with no serious complications. Sphincterotomy did not significantly lower resting gallbladder volume from 63.2±10.8 to 50.1±5.9 mL (P>0.05), but significantly increased gallbladder ejection fraction from 0.41±0.13 to 0.63±0.16 (P<0.01), as measured by the lipoid food test. The static liver and gallbladder imaging examination also showed an increase in gallbladder ejection fraction from 0.45±0.08 to 0.68±0.11 (P<0.01). In addition, the choledochus pressure reduced from 21.9±4.0 to 15.6±2.5 mm Hg, and the gallbladder muddy stones or sludge disappeared after endoscopic sphincterotomy. At the end of the follow-up period, there was no relapse of sludge or muddy stones in the gallbladder. CONCLUSIONS: The formation of gallbladder muddy stones or sludge is associated with papilla disease. Endoscopic sphincterotomy can resolve papilla disease, decrease gallbladder bile stasis, improve gallbladder evacuation, and prevent the formation of gallbladder stones.

Artifacts of the common bile duct caused by a duodenal metallic hemoclip on magnetic resonance cholangiopancreatography

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A rare cause of acute abdomen: spontaneous common hepatic duct perforation.

Spontaneous extrahepatic bile duct perforation is generally seen in infants. Although rarely seen in adults, it may be seen with fatal bile peritonitis. Therefore, for a patient presenting with acute abdominal symptoms, differential diagnosis must be made with radiological imaging such as abdominal ultrasonography or computed tomography, without any loss of time. In these imaging tests, in cases of gallstone disease together with perihepatic free fluid or choledocus which can not be monitored, it should be considered in the differential diagnosis. An emergency surgical intervention should be planned to avoid serious complications. The aim of this paper was to present the rare cause of acute abdomen which developed associated with spontaneous common hepatic canal perforation in an adult.

Rare case of Mirizzi syndrome associated with cholecystogastric fistula.

A woman in her mid-30s presented with upper right quadrant abdominal pain. On examination, there was mild upper right quadrant tenderness and negative Murphy's sign. Basic laboratory investigations revealed normal results except for elevated alkaline phosphatase. Subsequent imaging revealed chronic calculous cholecystitis and the dilated common bile duct harbouring stones, with pneumobilia. The patient underwent open cholecystectomy with common bile duct exploration. Intraoperatively, the gallbladder was found contracted, and densely adherent to and fistulising with the common bile duct and stomach.