Chronic cough caused by choledochoduodenal fistula: a case report.

BACKGROUND: Chronic cough is characterized by cough as the only or main symptom, with a duration of more than 8 weeks and no obvious abnormality in chest X-ray examination. Its etiology is complex, including respiratory disease, digestive system disease, circulation system disease, and psychological disease. Although a set of etiological diagnosis procedures for chronic cough have been established, it is still difficult to diagnose chronic cough and there are still some patients with misdiagnosis. CASE PRESENTATION: We present a case of a 54-year-old female patient who had chronic cough for 28 years. Physical examination had no positive signs and she denied any illness causing cough like tuberculosis, rhinitis. Recurrent clinic visits and symptomatic treatment didn't improve the condition. Finally, gastroscopy identified the possible etiology of choledochoduodenal fistula that was proved by surgery. And after surgery, the patient's cough symptoms were significantly improved. CONCLUSION: We report a rare case of chronic cough caused by choledochoduodenal fistula which demonstrates our as yet inadequate recognition of the etiology and pathogenesis. Written informed consent was obtained from the patient.

Case Report: Surgical Intervention for Fasciolopsis buski Infection: A Literature Review.

Fasciolopsis buski, also called the giant intestinal fluke, is the largest intestinal fluke of the zoonotic trematode parasites and found mainly in Southeast Asian countries, including China. Fasciolopsis buski infection was formerly a common health problem in many countries, but it is now rare. Typically, it can be cured by oral drugs, but some infected patients need surgical intervention because of the severity of their condition or because of an unclear diagnosis or even misdiagnosis. Here, we report a case of a 15-year-old girl from Guizhou Province, China, presenting with recurrent upper-middle abdominal pain that was misdiagnosed as a choledochal cyst. Through laparotomy combined with postoperative histopathological examination, the source of the pain was proven to be mechanical biliary obstruction caused by F. buski infection. In the past, mechanical obstruction, especially biliary obstruction, caused by F. buski infection leading to surgery was not uncommon, but it is very rare in modern society. Moreover, delayed treatment and misdiagnosis of parasitic infection can lead to severe consequences. Therefore, we reviewed the previous literature on F. buski infection treated by surgical operation and summarized the characteristics and therapeutic strategies of these cases to raise clinicians' awareness of this rare infection.

Approaches to Biopsy and Resection Specimens from the Ampulla.

The ampulla of Vater gives rise to a versatile group of cancers of mixed/hybrid histologic phenotype. Ampullary carcinomas (ACs) are most frequently intestinal or pancreatobiliary adenocarcinomas but other subtypes, such as medullary, mucinous, or signet ring/poorly cohesive cell carcinoma, may be encountered. Ampullary cancer can also be subclassified based on immunohistochemical features, however these classification systems fail to show robust prognostic reliability. More recently, the molecular landscape of AC has been uncovered, and has been shown to have prognostic and predictive significance. In this article, the site-specific, histologic, and genetic characteristics of ampullary carcinoma and its precursor lesions are discussed.

Mirizzi syndrome: a challenging diagnosis. Case report.

Mirizzi Syndrome (MS) is an uncommon complication of chronic gallstone disease defined as a common bile duct (CBD) obstruction secondary to gallstone impaction in the cystic duct or gallbladder neck. MS is still a challenging clinical situation: preoperative diagnosis of MS is complex and can be made in 18-62.5% of patients. Over 50% of patients with MS is diagnosed during surgery. In most of cases, laparotomy is the preferred surgical approach. We report the case of a 70-year-old woman with a history of asthenia, jaundice, abdominal pain and preoperative imaging that suggest the presence of biliary stones with a choledocal stenosis. Intraoperatively, a MS with cholecysto-biliary fistula involving less than two-thirds of the circumference of the bile duct was diagnosed and successfully treated.

Technical Aspects of Bile Duct Evaluation and Exploration: An Update.

Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.

Ectopic papilla of Vater in duodenum bulb: A hospital-based study.

The major papilla of Vater can be ectopically present in the stomach, pyloric canal, duodenal bulb, and third or fourth portion of the duodenum. In this study, we determined the clinical significance of ectopic papilla of Vater by endoscopic retrograde cholangiopancreatogram (ERCP).A retrospective study was conducted by reviewing the medical records of 6133 patients receiving ERCP from 1988 to 2011. The diagnosis was confirmed if both the common bile duct (CBD) and the main pancreatic duct (PD) drained into the same opening, either by ERCP or magnetic resonance cholangiopancreatography.Eight patients with major papilla of Vater in the duodenal bulb were identified among 6133 patients receiving ERCP from 1988 to 2011, with an incidence rate of 0.13%. The mean age was 67 years and patients were predominantly male. Duodenal bulb deformity was noted in all patients and three of them had shallow gastric and/or duodenal ulcers. Hook-shaped CBD configuration was seen only in half of our cases. Three patients with CBD stones were treated successfully after endoscopic sphincterotomy or papillary balloon dilation.Ectopic orifice of papilla is a rare finding of ERCP. Opacification of both the CBD and main PD from the same opening is an essential criterion for diagnosing an ectopic papilla of Vater in the duodenal bulb.

Choledochoduodenal Fistula Secondary to Peptic Ulcer Disease: A Case Report.

BACKGROUND Choledochoduodenal fistula is an uncommon complication secondary to peptic ulcer disease. Determining this diagnosis is challenging especially when confronted with unspecific physical and radiological findings. CASE REPORT Here we report a case of a 29-year-old Ethiopian female who presented to Geitaoui University Hospital in Beirut, Lebanon with epigastric pain and was diagnosed to have of choledochoduodenal fistula. CONCLUSIONS Choledochoduodenal fistula is a rare complication of duodenal ulcer and this case report may help clinicians to identify suspected cases of this entity with similar presentations.

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.

Double guidewire endoscopic technique, a major evolution in endoscopic retrograde cholangiopancreatography: Results of a retrospective study with historical controls comparing two therapeutic sequential strategies.

BACKGROUND AND AIM: Endoscopic access to the common bile duct (CBD) remains difficult in 10% of cases, requiring alternative techniques .CBD access was difficult after either five unsuccessful attempts, five unintentional insertions into the pancreatic duct or >10-min-long unsuccessful attempts. This retrospective study with historical controls aimed to evaluate the benefit of the double guidewire (DGW) technique after failure of standard CBD cannulation. METHODS: From January 2012 to December 2014, all patients requiring therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with difficult access to CBD were included in a Studied group. This group was compared to a historical ERCP control group from January 2009 to December 2011. In the Studied group, a sequential strategy including DGW technique was done when the guidewire was unintentionally passed into the pancreatic duct. In the control group, only pre-cut technique was used. RESULTS: Among the 538 patients with naive papilla eligible for ERCP, 73 had difficult CBD access. Successful CBD access rate was higher in the Studied group: 91% (50/55) versus 67% (12/18) P = 0.0215. Complication rates were similar in both groups: 28% versus 20%, P = 0.5207. LOS was shorter in the Studied group (9.2 ± 8.5 vs 14.4 ± 7.4 days, P = 0.0028). Post-ERCP cholangitis were lower in the Studied group: 2% (1/55) versus 22% (4/18), P = 0.0118. CONCLUSION: After standard cannulation failure, DGW technique increased successful CBD access rate and decreased LOS without increasing complications.

Cholesterol polyps in the distal common bile duct: a case report.

RATIONALE: Cholesterol polyps are rare in the common bile duct and difficult to diagnose. PATIENT CONCERNS: The small polypoid lesions often go undetected when using routine imaging methods, such as ultrasonography. DIAGNOSES: We treated a patient with cholesterol polyps in the common bile duct. After failing to detect choleliths using ultrasonography, magnetic resonance cholangiopancreatography revealed mild dilation of the common bile duct. Choledochoscopy was performed during laparoscopic cholecystectomy, which revealed yellowish-white polyps circumferentially distributed across the luminal surface of the distal common bile duct. Histological examination of biopsy specimens indicated cholesterol polyps with characteristic foamy cells. INTERVENTIONS: The patient was treated with ursodeoxycholic acid, and the number of polyps was found to have been reduced at the 6-week follow-up based on T-tube choledochoscopic examination. OUTCOMES: Recovery was unremarkable, and the ursodeoxycholic acid treatment was discontinued at the 6-month follow-up. LESSONS SUBSECTIONS: Our findings suggest that this rare condition can be treated pharmacologically to avoid potential postsurgical complications following resection of the distal common bile duct.

Frey procedure combined with biliary diversion in chronic pancreatitis.

BACKGROUND: The Frey procedure has become the standard operative treatment in chronic painful pancreatitis. Biliary diversion could be combined when associated with common bile duct obstruction. The aim of the present study was to evaluate the impact of the type of biliary diversion combined with the Frey procedure on late morbidity. METHODS: The data from consecutive patients undergoing the Frey procedure and having a minimum follow-up of 2 years were extracted from a maintained prospective database. The mean endpoint was the rate of secondary biliary stricture after the Frey procedure combined with biliary diversion (bilioenteric anastomosis or common bile duct reinsertion in the resection cavity). RESULTS: Between 2006 and 2013, 55 consecutive patients underwent the Frey procedure. Twenty-nine patients had common bile duct obstruction (52.7%). The technique of biliary diversion resulted in bilioenteric anastomosis in 19 patients (65.5%) and common bile duct reinsertion in 10 patients (34.5%). Preoperative characteristics and early surgical outcomes were comparable. Pain control was similar. There was significantly more secondary biliary stricture after common bile duct reinsertion than after bilioenteric anastomosis (60% vs 11%, P = .008). CONCLUSION: Combined bilioenteric anastomosis during the Frey procedure is an efficient technique for treating common bile duct obstruction that complicates chronic painful pancreatitis. Bilioenteric anastomosis was associated with less secondary biliary stricture than common bile duct reinsertion in the pancreatic resection cavity.