Estenosis crítica de conducto hepático común por anillo vascular: reporte de un caso / Common bile duct stricture caused by vascular ring: A case report

Introduction: The most common congenital malformations of the bile duct are biliary atresia and choledochal cyst. In addition, the most common liver anatomical variation is the right hepatic artery aberration. The goal of this study is to characterize a patient with this disease and propose the hepatoduodenal anastomosis as surgical treatment. Case report: One-month-old patient with suspected congenital biliary atresia due to progressive jaundice and acholia since birth. Liver tests consistent with a cholestatic pattern and brain MRI scan consistent with biliary atresia. Periods of decreased bilirubin and sporadic slight pigmentation of depositions were described. The surgical finding was a bile duct stricture due to a vascular ring caused by aberrant right hepatic artery. Resection of bile duct and hepatic-duodenal bypass were performed. The patient evolved satisfactorily from this condition. Conclusion: There are few reports of biliary obstruction due to vascular malformations. It is important to keep in mind that not all neonatal jaundice episodes are caused by biliary atresia or choledo-chal cyst. The clinical course, laboratory tests and imaging should be considered and in the case of suspicion, further exploration should take place.

Introducción: Las malformaciones congénitas de la vía biliar más frecuentes son la atresia de vías biliares y quiste de colédoco. Por otro lado, la variante anatómica hepática más común es la aberración de la arteria hepática derecha. El objetivo es caracterizar un paciente portador de esta patología y plantear la hepato-duodeno anastomosis como tratamiento quirúrgico. Caso clínico: Paciente de 1 mes de edad, con sospecha de Atresia de Vía Biliar congénita por ictericia progresiva y acolia desde recién nacido. Pruebas hepáticas concordantes con un patrón colestásico y resonancia magnética compatible con atresia de vías biliares. Evolucionó con períodos de descenso de bilirrubina y leve pigmentación, esporádica, de deposiciones. El hallazgo quirúrgico fue una estenosis crítica de vía biliar a nivel del conducto hepático común debido a un anillo vascular por una arteria hepática derecha aberrante. Se realizó una sección de vía biliar y una derivación hepato-duodenal. Evolucionó con una resolución completa de su patología. Conclusión: Existen pocos reportes de obstrucción de vía biliar por malformaciones vasculares. Es importante tener presente que no todas las ictericias neonatales son por atresia de vías biliares o quiste de colédoco. Se debe considerar la evolución clínica, laboratorio e imágenes, y si existen sospechas, explorar.

Utilidad de la cintigrafía de vía biliar en el diagnóstico diferencial de colección intrahepática: l caso clínico / Usefulness of bile duct scintigraphy in the differential diagnosis of intrahepatic collection: a clinical case

Se presenta el caso clínico de un paciente de 48 años referido por cuadro clínico de dolor abdominal y omalgia derecha de 6 meses de evolución posterior a colecistectomía y resección hepatobiliar por Cancer vesicular. El TAC abdominal demostró una gran colección quística intrahepática. El AngioTAc no mostró comunicación vascular. Frente a la sospecha de un bilioma se efectuó cintigrafía de la vía biliar con Tc99m-DISIDA. Ésta demostró un gran defecto de captación intrahepático de límites netos que reemplazaba casi todo el lóbulo derecho, un lóbulo izquierdo de contraste normal y presencia de paso enlentecido del radiofármaco hacia intestino, hallazgos cintigráficos no sugerentes de un bilioma. Se efectuó una punción percutánea de la lesión bajo TAC la cual dió salida a contenido hemático oscuro. Inmediatamente después de efectuar una evacuación parcial se realizó un nuevo AngioTAC el cual confirmó sangramiento activo subcapsular en napa desde segmento VI del hígado como complicación tardía de colecistectomía.

An hepatobiliary scintigraphy with Tc-99m diisopropyl iminodiacetic acid (DISIDA) was done in a 48-year-old man who consulted for abdominal and right shoulder pain 6 months following hepatobiliary and gallbladder resection for a gallbladder cancer. The abdominal CT showed a huge intrahepatic cystic collection. The Angio-CT showed no vascular communication. Biliary scintigraphy with DISIDA showed a large cold intrahepatic defect in the right lobe not compatible with diagnosis of bilioma. The percutaneus punction revealed an haematic collection. After partial percutaneus evacuation done under CT, a new Angio-CT showed active subcapsular hepatic bledding from segment VI of the liver as a late complication of gallbladder surgery.

Parásitos de fasciola hepática intracoledociano / Common bile duct fasciolasis: report of one case

La fasciolasis es una enfermedad parasitaria producida por el tremátodo digeneo Fasciola hepática. Durante la fase crónica de la enfermedad los parásitos pueden entran en los conductos biliares, y ser causa de ictericia obstructiva, colangitis, pancreatitis y otras complicaciones. Se presenta el caso clínico de una paciente intervenida por sospecha de colelitiasis y colédocolitiasis, a la cual durante la exploración coledociana intraoperatoria le fueron extraídos múltiples parásitos adultos de Fasciola hepática. Este hallazgo sólo fue aclarado posteriormente en la biopsia diferida. Se realiza una revisión breve del tema, métodos de diagnóstico, tratamiento médico y alternativas quirúrgicas de tratamiento.

Fasciolasis is a zoonotic disease caused by the digenean trematode Fasciola hepatica. During the chronic phase of the disease the parasites invade the main biliary ducts, causing obstructive jaundice, cholangitis, pancreatitis and other complications. We report a 75 years old female, operated due to the suspicion of a choledocholithiasis. During the exploration of the choledochus, adult F. hepatica parasites were extracted. The pathology report of the parasites confirmed the diagnosis.

Common bile duct pathologies at Nawabshah

To determine the causes, prentation, management and outcome of Common Bile Duct [CBD] pathologies. Descriptive analytical study from January 1995 to December 2006. Surgical Unit-I, Nawabshah Medical College and Hospital, Nawabsheh. All patients who presented with CBD pathologies. Data of all the patients with CBD pathologies was collected and entered on a proforma, including their complaints, positive examination findings, investigation, diagnosis, procedure performed and its outcome. During the study period 45 patients presented with CBD pathology. Amongst them 14 were males and the rest females [31], with a mean age of 36.7 years. Around 67% patients had choledocholithiasis as the commonest cause. Exploration of the CBD with T-tube insertion was the commonest procedure, performed in 69% patients. About 4% patients had retained stones and 20% developed wound infection. Mean hospital stay was 13 days. Most common pathology involving the CBD was secondary stones; 95% patients had associated gall stones also

Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management

RACIONAL: A síndrome de Mirizzi, é complicação rara da colelitíase de longa duração, caracterizada pelo estreitamento do ducto hepático comum devido a mecanismo de compressão e/ou inflamação por cálculos biliares impactados no infundíbulo da vesícula biliar ou no ducto cístico. OBJETIVO: Descrever série de oito enfermos consecutivos com síndrome de Mirizzi de uma única instituição, submetidos ao tratamento cirúrgico e comentar seus aspectos com ênfase no diagnóstico e tratamento. MÉTODO: Quatro mulheres e quatro homens, com média de idade de 61,6 anos (42 a 82 anos), foram operados com síndrome de Mirizzi entre 1997 e 2003. Avaliaram-se a apresentação clínica, os resultados dos exames laboratoriais e de imagem, os achados operatórios, a presença de coledocolitíase, o tipo de síndrome de Mirizzi de acordo com a classificação de Csendes, a escolha do procedimento operatório e as complicações pós-operatórias. RESULTADOS: Os sintomas mais freqüentes foram dor abdominal (87,5%) e icterícia (87,5%). Todos os doentes apresentaram exames de função hepática alterados. O diagnóstico da síndrome de Mirizzi foi intra-operatório em sete (87,5%) doentes, e pré-operatório em um (12,5%). Observou-se fístula colecistocoledociana associada à coledocolitíase em três (37,5%) casos. A síndrome de Mirizzi foi classificada como tipo I em cinco (71,4%) doentes, tipo II em um (14,3%), tipo III em um (12,5%), e tipo IV em outro (12,5%). A colecistectomia, como procedimento cirúrgico isolado, foi realizada em quatro (50,0%) doentes. Um (12,5%) enfermo foi submetido a colecistectomia parcial e fechamento do orifício fistuloso com a região central do infundíbulo. Dois (25,0%) enfermos foram submetidos a colecistectomia e anastomose coledocoduodenal látero-lateral e outro (12,5%) a anastomose coledocoduodenal látero-lateral, deixando-se a vesícula biliar in situ. Sete (87,5%) doentes evoluíram sem complicações pós-operatórias e obtiveram alta hospitalar em boas condições. Um (12,5%) enfermo apresentou, no pós-operatório, sepse por abscesso sub-hepático, sendo re-operado. Não houve mortalidade operatória. CONCLUSÕES: O diagnóstico pré-operatório da síndrome de Mirizzi é difícil e é necessário elevado índice de suspeita para evitar lesões da árvore biliar. O problema pode se tornar evidente apenas no momento da operação na forma de aderências firmes ao redor do triângulo de Calot. O sucesso do tratamento está relacionado ao reconhecimento...

A Case of Spontaneous Perforation of the Common Bile Duct Associated with Cholangitis / 대한소화기학회지

Spontaneous perforation of the common bile duct (CBD) is a rare event in adults. Most cases of CBD perforation are iatrogenic after invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy. We report a case of an 81-year-old woman who presented with severe right upper abdominal pain, fever, and chills. Abdominal CT showed multiple gallbladder and CBD stones and loculated fluid collection in the inferoposterior portion of the stomach. ERCP showed the leakage of contrast media into the peritoneal cavity from the CBD. We performed endoscopic sphincterotomy (EST) and endoscopic nasobiliary drainage (ENBD) to decompress the CBD instead of emergent surgical intervention. One week later, cholangiography via ENBD tube revealed that there was no more leakage of the contrast media from the CBD. We performed cholecystectomy, removal of the CBD stones after exploration of the CBD, and T tube insertion. The perforated site of the CBD was closed and there was no more fluid collection in the inferoposterior portion of the stomach. Medical treatment including endoscopic procedures was useful for healing of the perforated CBD.

Vanishing bile duct syndrome in Hodgkin's disease: case report

CONTEXT: Liver damage is relatively common in patients affected by Hodgkin's disease. A smaller proportion of cases develops jaundice. Recently, the vanishing bile duct syndrome was described in Hodgkin's disease. The mechanisms of this severe complication have been poorly understood until now. OBJECTIVE: To describe a rare case of intra-hepatic cholestasis due to vanishing bile duct syndrome. DESIGN: Case report. CASE REPORT: A 38-year-old male patient affected by Hodgkin's disease. Liver biopsy showed no detectable Hodgkin's disease. Intra-hepatic cholestasis was found and none of the six portal tracts analyzed contained normal bile ducts. The treatment was based on conventional and high-dose escalation chemotherapy. The patient died from an irreversible liver failure while in complete remission from Hodgkin's disease

Pitfalls in the management of Mirizzi's syndrome.

Pressure on the common hepatic duct due to a gallstone impacted in Hartmann's pouch or cystic duct results in jaundice and cholangitis. Repeated episodes of inflammation and pressure necrosis lead to the formation of a cholecysto-choledochal fistula (Mirizzi's syndrome Type I & II). Preoperative diagnosis is difficult and a formal cholecystectomy may lead to bile duct injury. Of the 792 patients operated upon for symptomatic gallstone disease from June 1992 to June 1997 at our centre, 18 patients (2%) had Mirizzi's syndrome. There were 11 females and 5 males, with a mean age of 48 (SD 20; range 20-74) years. Thirteen patients (81%) presented with cholangitis. Ultrasound scan suggested the diagnosis of carcinoma gallbladder in 9 (56%). Endoscopic Retrograde Cholangiopancreatography (ERCP) confirmed the diagnosis in 16. Cholecystectomy was done by the fundus first technique. A complete cholecystectomy was done only if there was no cholecysto-choledochal fistula (n = 5), otherwise a cuff of gallbladder was used to repair the bile duct (n = 10). Hepatico-jejunostomy was done to drain the fistula in one patient. A T-tube drain was placed in the common bile duct (CBD) and a cholangiogram done, before closing the abdomen in all. Histology revealed carcinoma in fundus of gallbladder in one patient (6%). One patient died of haemobilia 3 weeks after operation. Wound infection developed in 5 (30%) patients and 12 (75%) have been followed up for a median period of 28 months. One patient developed a biliary stricture with intrahepatic stones and later underwent a hepatico-jejunostomy. Two have undergone repair of incisional hernia. High index of clinical suspicion, ERCP to clinch the diagnosis, NBD to drain the infected bile, a fundus first partial cholecystectomy and primary repair of CBD, followed by a peroperative T-tube cholangiogram, usually leads to a satisfactory outcome.

von Hippel Lindau syndrome presenting as obstructive jaundice with involvement of pancreas in two siblings.

Von Hippel Lindau disease is rare autosomal dominant disorder. In our patient's family, 4 out of 7 siblings had manifestations of the disease; 3 of those affected had pancreatic lesions with obstructive jaundice in 2 siblings caused by pancreatic cysts is reported for the first time.

Icterus due to tumor emboli--a rare presentation of hepatoma.

Two cases of hepatocellular carcinoma presenting with features of obstructive jaundice are reported because of their unusual presentation. Both of them had obstruction of the common bile duct by tumor emboli and underwent palliation with surgical evacuation of the tumor thrombus.

Estenosis benigna de vía biliar: dilatación percutánea en un caso / Bening common bile duct stenosis: percutaneous dilatation in a case

A 41 year old woman developed obstructive biliary tract disease 3 years after cholecystectomy. A surgical attempt to relieve the obstuction failed and a benign stricture of the common duct was shown at cholangiography. Percutaneous dilatation of the stricture was performed through the draining tube with exellent clinical and laboratory results

Choledochoduodenal fistula complicating duodenal ulcer disease (a report of 3 cases).

Choledochoduodenal fistula complicating duodenal ulcer disease is a rare occurrence. The present paper describes 3 such cases which were incidentally picked up on upper gastro-intestinal (GI) radiographic study and endoscopy done for ulcer like symptoms. The relevant literature is reviewed.

Resolución espontánea del síndrome del fondo de saco retroduodenal (sump syndrome) / Spontaneous remission of the syndrome of tetroduodenal sac fundus (sump syndrome)

El síndrome del fondo de saco retroduodenal, o Sump syndrome (SS), es una infrecuente complicación alejada de las dereivaciones biliodigestivas quirúrgicas (coledocoduodenoanastomosis y coledocoyeyunoanastomosis) y consiste en el acúmulo de cálculos, contenido gastrointestinal y bilis litogénica a nivel del colédoco distal entre la neoboca quirúrgica y la papila duodenal. El cuadro clínico depende de las complicaciones de la enfermedad biliar litiásica: dolor abdominal, pancreatitis aguda y colangitis. La ictericia aparece cuando también se obstruye la anastomosis quirúrgica. El diagnóstico surge por la radiologia invasiva de la via biliar e históricamente el tratamiento fue el quirúrgico, pero hoy se considera que el efectivo es la papilotomía endoscópica. Aquí presentamos cuatro casos de SS diagnosticados por colangiografia percutánea (3 casos de acuerdo a las descripciones originales y uno asociado a una lesión quirúrgica de la vía biliar principal), los cuales tuvieron buena evolución en un seguimiento de 2 a 8 años (5 de promedio), en donde el mayor interés reside en que se pudo documentar la resolución espontánbea del SS no interferida por tratamiento alguno, quirúrgico o endoscópuico sobre la papila duodenal, en dos pacientes que hicieron el parto espontáneo de los cálculos y en otros dos (por negativa al tratamiento en uno y contraindicaciones generales en el restante) que aún presentan los cálculos en el fondo del saco ciego biliar, lo cual que si la derivación biliodigestiva...

Choledocho-duodenal fistula due to tuberculosis.

An unusual case of caseating nodal tuberculosis causing a choledocho-duodenal fistula is reported. Anti-tubercular treatment led to closure of the fistula.

Quistes del Coledoco: Diagnostico y tratamiento; presentacion de 6 Pacientes / Choledochus cysts: Diagnosis and treatment; report of 6 patients

Se presentan y discuten 6 pacientes con quistes del coledoco, 4 mujeres y 2 hombres en la primera y en la segunda decada de la vida. Tan solo en 3 casos se encontro la triada de masa, dolor e ictericia. Se hace enfasis en los estudios de imagenes que ayudaron en el diagnostico. Se analizan las historias clinicas y el tratamiento quirurgico elegido en cada caso