A Pilot Study for Biliary Atresia Diagnosis: Fluorescent Imaging of Indocyanine Green in Stool.

BACKGROUND: Biliary atresia is the most common cause of obstructive jaundice in infants and conventional cholangiography is the current diagnostic gold standard. Fluorescent cholangiography with indocyanine green can enhance biliary tree visualization during surgery because it is exclusively excreted into the bile ducts and eventually into the intestine. Therefore, we hypothesized that indocyanine green presence in stool could confirm bile duct patency in infants. METHODS: A prospective single center cohort study was performed on infants (age ≤ 12 months) with and without jaundice after obtaining IRB approval. Indocyanine green was administered intravenously (0.1 mg/kg). Soiled diapers collected post-injection were imaged for fluorescence. RESULTS: After indocyanine green administration, fluorescence was detected in soiled diapers for control patients (n = 4, x = 14 h22 m post-injection) and jaundiced patients without biliary atresia (n = 11, x = 13 h28 m post-injection). For biliary atresia patients (n = 7), post-injection soiled diapers before and after Kasai portoenterostomy were collected. Fluorescence was not detected in stool from 6 of 7 biliary atresia patients. As a test, indocyanine green detection in stool was 97% accurate for assessing biliary patency. CONCLUSION: Fluorescent Imaging for Indocyanine Green (FIInd Green) in stool is a fast and accurate approach to assess biliary patency non-invasively in infants. LEVEL OF EVIDENCE: Level III.

Preoperative endoscopic ultrasound-guided biliary drainage for primary drainage in obstructive jaundice.

INTRODUCTION: Endoscopic transpapillary approach by endoscopic retrograde cholangiopancreatography (ERCP) is the established technique for preoperative biliary drainage (PBD). Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been reported to be a useful alternative technique after ERCP fail. However, the optimal strategy remain controversial. AREA COVERED: This review summarizes the literature on EUS-BD techniques for PBD with a literature search using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials database between 2000 and 2023 using keywords for 'preoperative biliary drainage' and all types of EUS-BD techniques. EXPERT OPINION: As there is no consensus on the optimal EUS-BD technique for PBD, selection of the EUS-BD approach depends on the patient's condition, the biliary obstruction site, the anastomosis after surgical intervention, and the preference of the endoscopist. However, we consider that EUS-HGS using a dedicated plastic stent may have some advantages in the adverse impact of surgical procedure because the location where the fistula is created by EUS-HGS is away from the site of the surgical procedure. Although there remain many issues that require further investigation, EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.

Obstructive jaundice as a rare complication of multiple pancreaticoduodenal artery aneurysms due to median arcuate ligament syndrome: a case report and review of the literature.

BACKGROUND: Obstructive jaundice has various causes, and one of the rarest is pancreaticoduodenal artery aneurysm (PDAA), which is often associated with celiac axis stenosis caused by median arcuate ligament syndrome (MALS). CASE PRESENTATION: The patient was a 77-year-old Azeri woman who presented with progressive jaundice, vague abdominal pain, and abdominal distension from 6 months ago. The intra- and extrahepatic bile ducts were dilated, the liver's margin was slightly irregular, and the echogenicity of the liver was mildly heterogeneous in the initial ultrasound exam. A huge cystic mass with peripheral calcification and compressive effect on the common bile duct (CBD) was also seen near the pancreatic head, which was connected to the superior mesenteric artery (SMA) and had internal turbulent blood flow on color Doppler ultrasound. According to the computed tomography angiography (CTA) findings, the huge mass of the pancreatic head was diagnosed as a true aneurysm of the pancreaticoduodenal artery caused by MALS. Two similar smaller aneurysms were also present at the huge aneurysm's superior margin. Due to impending rupture signs in the huge aneurysm, the severe compression effect of this aneurysm on CBD, and the patient's family will surgery was chosen for the patient to resect the aneurysms, but unfortunately, the patient died on the first day after the operation due to hemorrhagic shock. CONCLUSION: In unexpected obstructive jaundice due to a mass with vascular origin in the head of the pancreas, PDAA should be considered, and celiac trunk should be evaluated because the main reason for PDAA is celiac trunk stenosis or occlusion by atherosclerosis or MALS. The treatment method chosen (including transarterial embolization, open surgery, or combined method) depends on the patient's clinical status and radiological findings, but transarterial embolization would be safer and should be used as a first-line method.

Effect of Biliary Tract Invasion with Obstructive Jaundice on the Prognosis of Patients With Unresectable Hepatocellular Carcinoma.

RATIONALE AND OBJECTIVES: Biliary tract invasion (BTI) is associated with poor outcomes in patients with hepatocellular carcinoma (HCC). However, the presence of a BTI is a neglected variable for staging in the current guidelines. This study aimed to explore the effects of BTI with obstructive jaundice on the prognosis of patients with unresectable HCC. METHODS: We retrospectively included 205 patients initially diagnosed with unresectable HCC who presented with obstructive jaundice due to BTI between January 2010 and June 2021. BTI was classified into four types according to the location of the biliary obstruction. Both clinical and treatment factors that affect median overall survival (mOS) were analyzed. RESULTS: The mOS of patients with Barcelona Clinic Liver Cancer (BCLC) stages B, C, and D was 9.2 months, 3.4 months, and 1.8 months, respectively (p<.001). The mOS of BTI type I patients was superior to that of BTI type II patients (7.1 months vs. 3.2 months, p=.002). Patients who underwent successful biliary drainage had a longer mOS than those who underwent unsuccessful biliary drainage (10.4 months vs. 2.9 months, p<.001). In the multivariate analysis, BTI type I (p=.009), successful biliary drainage (p=.005), and HCC treatment (p<.001) were significant favorable prognostic factors that affected patient survival. CONCLUSION: HCC patients with BTI type II may have a poorer prognosis than those with BTI type I. Effective biliary drainage and anti-cancer treatment may provide survival benefits to these patients. A more detailed staging system for HCC based on the state of BTI is needed.

Magnetic Resonance Cholangiopancreatography to Evaluate Improvement Effect of FXR Regulating Bile Acid on Hepatocellular Carcinoma with Obstructive Jaundice.

This research aimed at exploring the improvement effect of Farnesoid X receptor (FXR) regulating bile acid (BA) on hepatocellular carcinoma with obstructive jaundice under magnetic resonance cholangiopancreatography (MRCP). Forty-eight hepatocellular carcinoma patients with obstructive jaundice who were examined in hospital were selected as the study group, and another 10 healthy volunteers who were examined at the same period were selected as the control group. The patients were treated with FXR inhibitor, and the therapeutic effect was observed. The results showed that after treatment, the AST content and TBIL content in serum of the study group were 123.5 ± 4.9 U/L and 1.8 ± 0.3 µmol/L, respectively, which were significantly lower than those before treatment, P < 0.05; the ALT content and AST content in serum in patients with high obstruction were significantly lower than those before treatment, and the K+ content was significantly higher than that before treatment (P < 0.05). The ALT, AST, and TBIL contents in serum in patients with low obstruction were significantly lower than those before treatment (P < 0.05). Apparent diffusion coefficient (ADC) was 1.17 ± 0.49 × 10-3 mm2/s in patients with moderate jaundice and 1.20 ± 0.27 × 10-3 mm2/s in patients with severe jaundice, compared with that before treatment, and the difference was statistically significant (P < 0.05). Based on FXR, it can regulate BA synthesis and metabolism, restore BA metabolic homeostasis, effectively play a hepatoprotective role, reduce bilirubin content in the body, and improve jaundice injury, which has application value.

ERCP and situs inversus.

An 85-year-old female with situs inversus totalis was admitted due to obstructive jaundice, secondary to multiple choledocholithiasis and distal biliary stenosis due to adenocarcinoma of the head of the pancreas, with duodenal infiltration and metastatic liver disease. An endoscopic retrograde cholangiopancreatography (ERCP) was attempted in the supine position but bile duct cannulation was not possible due to duodenal infiltration. Finally, a palliative biliary stent was placed percutaneously, with resolution of the jaundice.

Obstructive Jaundice Caused by a Large Intact Abdominal Aortic Aneurysm. Case Report and Literature Review.

BACKGROUND: Obstructive jaundice caused by abdominal aortic aneurysm (AAA) is an extremely rare clinical presentation. We present an 85-year-old male with a large intact AAA causing obstructive jaundice and review the relevant literature. METHODS AND RESULTS: The patient was referred to our hospital with jaundice and a palpable pulsatile abdominal mass. Computerized tomography (CT) angiogram and magnetic resonance cholangiopancreatography (MRCP) revealed an infrarenal AAA with maximal diameter of 8.5 cm compressing the pancreatic head and common bile duct, causing obstructive jaundice with elevated levels of total, and direct bilirubin. The patient was subjected to endovascular aneurysm repair (EVAR). Blood bilirubin gradually decreased to normal levels. No complications were reported during the immediate postoperative and at 3-month follow up period. Literature review suggests that our case is one of the largest intact AAAs which have been reported to cause biliary obstruction. CONCLUSIONS: AAAs causing secondary obstructive jaundice is an uncommon clinical presentation requiring high clinical suspicion during differential diagnosis, so that patients can receive proper and early diagnosis and treatment.

Role of Magnetic Resonance Cholangiopancreatography in the Evaluation of Obstructive Jaundice.

Background Magnetic Resonance Cholangiopancreatography is a reliable and highly sensitive imaging modality in the diagnosis of Obstructive jaundice. Objective To evaluate the diagnostic accuracy of Magnetic Resonance Cholangiopancreatography as compared to Endoscopic Retrograde Cholangiopancreatography. Method A prospective, analytical study was conducted in the Department of Radiodiagnosis and Imaging at Dhulikhel Hospital between October 2018 and December 2020. Altogether 100 patients of all ages with obstructive jaundice undergoing Magnetic Resonance Cholangiopancreatography and Endoscopic Retrograde Cholangiopancreatography were included. The causes of obstructive jaundice as identified by Magnetic Resonance Cholangiopancreatography were compared to that of Endoscopic Retrograde Cholangiopancreatography considering Endoscopic Retrograde Cholangiopancreatography as gold standard for the diagnosis. Result Magnetic Resonance Cholangiopancreatography revealed choledocholithiasis in 60 (60%) patients, benign stricture - 14(14%), malignant stricture-11(11%), periampullary carcinoma in 8(8%) and normal study in 4(4%) patients. Endoscopic Retrograde Cholangiopancreatography showed choledocholithiasis in 59(59%) patients, strictures (benign in 13%, malignant in 10%), ascariasis in 3(3%) and normal findings in 5(5%) patients. The sensitivity, specificity, positive predictive value and negative predictive value of Magnetic Resonance Cholangiopancreatography in detecting choledocholithiasis were 96.6%, 92.3%, 95%, and 95%. The same values for benign strictures were 92.3%, 97.7%, 85.7% and 98.9%, whereas those for malignant strictures were 90.9%, 98.8%, 90.9% and 98.8%. All values were 100% for peri-ampullary carcinoma and ascariasis. Hence, Magnetic Resonance Cholangiopancreatography showed good accuracy for detecting causes of obstructive jaundice (p < 0.05) as compared to Endoscopic Retrograde Cholangiopancreatography. Conclusion Magnetic Resonance Cholangiopancreatography is an accurate, non-invasive technique in evaluation of obstructive jaundice and offers similar diagnostic value compared to Endoscopic Retrograde Cholangiopancreatography.

Revisiting Quincke's Triad: A Case of Idiopathic Hepatic Artery Aneurysm Presenting with Obstructive Jaundice.

INTRODUCTION: Hepatic artery aneurysm (HAA) is a rare occurrence. Quincke's triad of hemobilia; abdominal pain, obstructive jaundice, and upper gastrointestinal (GI) bleeding could be detected in one-third of HAA patients. CASE PRESENTATION: We present a case of HAA with all signs of Quincke's triad and shock. The diagnosis of HAA was enforced by CT angiography. An urgent open surgical approach was elected by the surgical team. The patient underwent an uneventful resection of the HAA, and primary repair of the CHA followed with bilioenteric reconstruction. CONCLUSIONS: Recognizing the signs of Quincke's triad aids in prompt diagnosis of hemobilia in HAA, which suggests a rupture of the aneurysm or fistula formation into the biliary tree that would need urgent management by both vascular and HBP surgeons.

Splenic Artery Pseudoaneurysm in Chronic Pancreatitis Causing Obstructive Jaundice: Endovascular Management.

BACKGROUND: Splenic artery pseudoaneurysm (SAP) around the pancreatic head causing obstructive jaundice is an extremely rare complication but can be life threatening once occurs. This case report is to raise awareness of this catastrophic complication and share our experience of successful endovascular management. METHODS: A 47-year-old male with a history of chronic pancreatitis clinically presented with epigastric pain and jaundice. Proximal SAP complicated with obstructive jaundice was confirmed by laboratory and imaging investigations. The SAP was successfully treated by transarterial coil embolization, and the jaundice subsequently improved. RESULTS: Abdominal contrast-enhanced computed tomography 11 months after embolization showed complete occlusion and reduction in the volume of the SAP as well as normal biliary tract. CONCLUSIONS: SAP complicated with obstructive jaundice should be managed timeously and aggressively once diagnosed, given its potential adverse consequences. Transarterial embolization using the isolation technique may be a safe and effective strategy for treating this disease.

A case of tuberculosis presented by obstructive jaundice tuberculosis-related mechanical icterus.

Obstructive jaundice caused by tuberculosis lymphadenitis is a rare condition. It can mimic clinical and radiological findings of hepatobiliary malignancies. The authors report a 24-year-old male patient who presented with abdominal pain, fever and jaundice for the last two weeks. It was found that cholestasis enzymes were increased by 2-3 fold and direct bilirubin was 6.13 mg/dL. Imaging studies revealed conglomerated lymph nodes with some cavitary lesions and dilated intrahepatic biliary canal secondary to compression by the lymph nodes. Tuberculosis was found to be positive in the polymerase chain reaction analysis of the aspirate that was obtained in the guidance of imaging studies. M. tuberculosis complex was isolated from mycobacterial culture. Anti-tuberculosis treatment was initiated. Clinical, laboratory and radiological findings completely resolved by medical therapy alone. Tuberculosis lymphadenitis should be kept in mind in cases presenting with obstructive jaundice in endemic areas and interventional diagnostic techniques should be preferred in eligible patients.

The Overall Poor Specificity of MRCP in the Preoperative Evaluation of the Jaundiced Patient Will Increase the Incidence of Nontherapeutic ERCP.

Laparoscopic cholecystectomy remains one of the most common surgical operations. Common bile duct stones (CBDS) are estimated to be present in 10%-20% of individuals with symptomatic gallstones. Preoperative magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography (IOC) remain the most common methods of evaluation, with subsequent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction if positive for CBDS. We examined our experience with preoperative MRCP versus IOC for the management of the jaundiced patient with cholelithiasis. This is a retrospective single-institution study that examined all laparoscopic cholecystectomies performed over a 15-month period between 2017 and 2018. Outpatient elective cases were excluded from the analysis. Charts were reviewed for demographics, operative details, and whether an MRCP, IOC, or ERCP was performed. Data were evaluated using a 2-sample t-test. A total of 460 patients underwent laparoscopic cholecystectomy over a 15-month period. Of those, 147 underwent either an MRCP or an IOC for clinical suspicion for CBDS. ERCP after MRCP was nontherapeutic in 11/32 (34%) compared with 2/12 (17%) of patients following IOC. The sensitivity and specificity of MRCP were 91% and 80%, respectively, with a positive predictive value of 66% and a negative predictive value of 96%. The sensitivity and specificity of IOC were 83% and 97%, respectively, with a positive predictive value of 83% and a negative predictive value of 97%. MRCP and IOC have unique advantages and disadvantages. MRCP has greater sensitivity, but poor specificity, resulting in unnecessary ERCPs with associated morbidity and increased costs to the patient.

Incidence and risk factors of pancreatitis in obstructive jaundice patients after percutaneous placement of self-expandable metallic stents.

BACKGROUND: Percutaneous transhepatic biliary drainage is an alternative treatment for patients with malignant distal biliary obstruction. The aim of this study was to investigate the occurrence of pancreatitis in patients who had undergone percutaneous placement of a biliary stent and to assess the risk factors for pancreatitis and the treatment outcomes. METHODS: From January 2010 to October 2016, 980 patients in our hospital who underwent percutaneous placements of self-expandable metallic stents for obstructive jaundice were retrospectively analyzed. The incidence of pancreatitis and risk factors were assessed by univariate and multivariate logistic regression analysis. Therapeutics, such as somatostatin, which were also adminstrated to release the symptom and promote the restoration of normal function of pancreas, were also analyzed. RESULTS: Pancreatitis occurred in 45 (4.6%) patients. One patient died from severe acute pancreatitis. Multivariate logistic regression analysis showed that common bile duct stent placement was the only independent risk factor that related to pancreatitis (odds ratio = 2.096, 95% CI: 1.248-5.379; P = 0.002). By using somatostatin, the concentrations of serum amylase and lipase were decreased in 44 patients with pancreatitis. No major complications were found during the treatment. CONCLUSIONS: Pancreatitis is a relatively low complication of percutaneous placement of biliary stents. The common bile duct stent placement is the only independent risk factor that related to pancreatitis. In this case, the percutaneous transhepatic biliary drainage is a preferred method for treatment. Furthermore, somatostatin is a secure and efficacious method to release the symptom and promote the restoration of pancreatic function.

Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction after failed ERCP in low performance status patients.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) with the placement of a biliary stent is the treatment of choice for palliation of malignant obstructive jaundice. In 5-10% of cases ERCP fails. In these cases an effective alternative is endoscopic ultrasonography-guided biliary drainage (EUS-BD). AIM: Evaluation of the principal clinical outcomes of direct transluminal EUS-BD. PATIENTS AND METHODS: This study is a retrospective analysis. All consecutive patients with malignant obstructive jaundice, in whom ERCP had failed, were enrolled. The primary outcome was the technical success of EUS-BD defined as the correct placement of the metal or plastic stent across the stomach or duodenum to the biliary tree. The most important secondary outcomes were early and late clinical success, both linked to the decrease of bilirubin haematic level. RESULTS: Between January 2011 and November 2017 thirty-six patients were included. Technical success was obtained in 91.6%. A clinical success, early or late was obtained in 75.8%. The ECOG performance status of less than 3 was correlated with clinical success. Adverse events occurred in 30.3% of patients. CONCLUSIONS: EUS-BD is an effective and safe procedure.