Migration of a biliary stent causing duodenal perforation and biliary peritonitis.

Migration of endoscopically placed biliary stents is a well-recognized complication of endoscopic retrograde cholangiopancreatography. Less than 1% of migrated stents however cause intestinal perforation. We present a case of a migrated biliary stent that resulted in duodenal perforation and biliary peritonitis.

Laparoscopic cholecystectomy in children with sickle cell anemia and the role of ERCP.

BACKGROUND: Patients with sickle cell anemia (SCA) have a high incidence of cholelithiasis and choledocholithiasis. This report is an analysis of our experience with laparoscopic cholecystectomy (LC) for children with SCA and the role of endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS: The records of children with SCA who had cholecystectomy were retrospectively reviewed for age, sex, hemoglobin level, hemoglobin electrophoresis, indication for cholecystectomy, operative time, hospital stay, and postoperative complications. They were divided into 2 groups, open cholecystectomy (OC) group and LC group, and the 2 were compared in terms of operative time, hospital stay, and postoperative complications. RESULTS: Over a period of 15 years (January 1995 and December 2009), 94 children with SCA had cholecystectomy. Thirty-five (19 males and 16 females) had OC, 52 (28 males and 24 females) had LC, and 7 (4 males and 3 females) had LC and splenectomy. Their age ranged from 4 to 15 years (mean, 11.4 y). The indications for cholecystectomy were biliary dyspepsia and biliary colic (55), acute cholecystitis (7), obstructive jaundice (17), asymptomatic (12), and biliary pancreatitis (3). All those who had OC underwent intraoperative cholangiogram, 9 of them (25.7%) had common bile duct (CBD) exploration and 2 transduodenal sphincterotomy. Of those who had LC, 13 (25%) underwent preoperative ERCP, which was normal in 1, showed dilated CBD with no stones in 2, and dilated CBD with stones in 7. In 3, ERCP showed dilated CBD with enlarged, inflammed papilla suggestive of recent stone passage. Nine underwent endoscopic sphincterotomy and stone extraction followed by LC. There was no mortality; 1 (2.1%) required conversion to OC and another underwent postoperative exploration because of bleeding from an accessory cystic artery. In the LC group, 4 (7.7%) developed minor postoperative complications, whereas 8 (22.9%) in the OC group developed complications. CONCLUSIONS: With proper perioperative management, LC is feasible, safe, and superior to OC in children with SCA with regard to postoperative complications, duration of hospital stay, cosmetic appearance, and postoperative recovery. LC should be the treatment of choice for both symptomatic and asymptomatic cholelithiasis in children with SCA. ERCP is a valuable diagnostic and therapeutic investigation both preoperatively and postoperatively. The sequential approach of endoscopic sphincterotomy and stone extraction followed by LC is a safe and effective approach for the management of cholelithiasis and choledocholithiasis in children with SCA.

Successful Treatment of Mirizzi's Syndrome Using SpyGlass Guided Laser Lithotripsy.

The majority of common bile duct stones can be effectively treated by endoscopic sphincterotomy and stone extraction using basket or balloon extractor. Stones more than 2 cm in diameter on the other hand require mechanical, electrohyraulic lithotripsy and sphincterotomy and balloon dilation. Mechanical lithotripsy may not be successful because of the size, consistency and site of the stones. In these cases, laser lithotripsy is the treatment of choice. This however requires direct visualization of the stone which may not be feasible for impacted cystic duct stones. This report describes the successful treatment of difficult cystic duct stones in two patients with Mirizzi's syndrome type I using per oral Spyglass and intraductal holmium: YAG Laser Lithotripter.

Role of ERCP in the era of laparoscopic cholecystectomy for the evaluation of choledocholithiasis in sickle cell anemia.

AIM: To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis in patients with sickle cell anemia (SCA) in the era of laparoscopic cholecystectomy (LC). METHODS: Two hundred and twenty four patients (144 male, 80 female; mean age, 22.4 years; range, 5-70 years) with SCA underwent ERCP as part of their evaluation for cholestatic jaundice (CJ). The indications for ERCP were: CJ only in 97, CJ and dilated bile ducts on ultrasound in 103, and CJ and common bile duct (CBD) stones on ultrasound in 42. RESULTS: In total, CBD stones were found in 88 (39.3%) patients and there was evidence of recent stone passage in 16. Fifteen were post-LC patients. These had endoscopic sphincterotomy and stone extraction. The remaining 73 had endoscopic sphincterotomy and stone extraction followed by LC without an intraoperative cholangiogram. CONCLUSION: In patients with SCA and cholelithiasis, ERCP is valuable whether preoperative or postoperative, and in none was there a need to perform intraoperative cholangiography. Sequential endoscopic sphincterotomy and stone extraction followed by LC is beneficial in these patients. Endoscopic sphincterotomy may also prove to be useful in these patients as it may prevent the future development of biliary sludge and bile duct stones.

Strongyloides stercoralis hyperinfection in a post-renal transplant patient.

Strongyloides stercoralis is an intestinal nematode that is able to infect the host tissue and persist asymptomatic for many years through autoinfection. It causes life-threatening hyperinfection in immunocompromised hosts. This report describes a rare case of strongyloidiasis in a 40-year-old male following renal transplant, which was diagnosed by colonoscopic biopsy. The literature on the subject is also reviewed.

Metastatic Malignant Melanoma of the Small Intestines Diagnosed by Capsule Endoscopy.

Malignant melanoma is a fairly common tumor that shows an unusual predilection to metastasize to the small intestines. The time interval between the diagnosis of metastasizing melanoma and the initial diagnosis is variable. This as well as the non specific symptoms and the fact that the small bowel is inaccessible both radiologically and endoscopically lead to delay in diagnosis. We present a case of metastatic malignant melanoma to the small intestines diagnosed several years post excision by capsule endoscopy. Metastatic melanoma in the small bowel should be suspected in any patient with a previous history of malignant melanoma who develops non specific gastrointestinal symptoms. Capsule endoscopy which is non invasive, convenient to the patient and devoid of radiation should form part of their diagnostic investigation.

Thromboembolism in inflammatory bowel diseases: a report from Saudi Arabia.

Thromboembolism (TE) is a serious but under-recognized complication of inflammatory bowel disease (IBD). This is specially so in developing countries where the incidence of IBD is low. In Saudi Arabia, IBD is considered to be rare, but the incidence is increasing. Where the clinical manifestations resemble those of developed countries, TE as a complication of IBD is considered to be very rare. This report describes six IBD patients with TE. This importance of the complication of TE is stressed, and physicians caring for these patients should be aware of it in order to obviate potential morbidity and mortality.

Safety of pegylated interferon and ribavirin therapy for chronic hepatitis C in patients with sickle cell anemia.

AIM: To evaluate the safety and efficacy of combined pegylated interferon and ribavirin for the treatment of chronic hepatitis C (HCV) in patients with sickle cell anemia (SCA). METHODS: Fifty-two patients with SCA and HCV were treated over a period of 7 years from June 2002 to July 2009. Their medical records were reviewed for: age at treatment, sex, body mass index, Hb level at the start of therapy and on follow-up, hemoglobin electrophoresis, liver function tests, G6PD level, LDH, bilirubin, HCV-RNA viral load, HCV genotype, liver biopsy, duration of treatment, and side effects. All were treated with pegylated interferon and a standard dose of ribavirin. The treatment was continued for 24 wk for those with genotype 2 and 3 and for 48 wk for those with genotype 1 and 4. RESULTS: Fifty-two patients (30 females and 22 males) were treated. Their mean age was 29.5 years (range 15-54 years). HCV genotype was determined in 48 and 15 had liver biopsy. Their mean pre-treatment HCV-RNA viral load was 986330 IU/mL (range 12762-3329282 IU/mL). The liver biopsy showed grade I in 6 and grade II in 9 and stage I in 13 and stage II in 2. Only 8 were receiving hydroxyurea at the time of treatment. All tolerated the treatment well and none experienced a decrease in their Hb which required blood transfusion pre, during or after therapy. There were no hematological side effects attributable to ribavirin at the usual recommended dose. Thirty-seven (71.2%) achieved SVR at 6 mo after the end of treatment. The remaining 15 were non-responders. Two of them showed an ETR but had a relapse. The remaining 13 had a relatively significant HCV-RNA viral load with a mean HCV-RNA viral load of 1829741.2 IU/mL (900000-3329282 IU/mL) and eight of them had HCV genotype 1, four had HCV genotype 4, and one had HCV genotype 5. CONCLUSION: Patients with SCA and HCV can be treated with pegylated interferon and ribavirin at the usual recommended dose. This is even so in those who are not receiving hydroxyurea. The treatment is safe and effective and the response rate is comparable to those without SCA.

Staple Line Polyposis and Cytomegalovirus Infection after Stapled Haemorrhoidectomy.

Early bleeding after stapled haemorrhoidectomy (SH) is not uncommon. Late and persistent bleeding occurring weeks or months after SH, however, is rare; it has only been described in more than 10% of cases. It is attributed to the development of inflammatory polyps at the staple line. Occurrence of rectal bleeding in the presence of palpable polypoid lesions at the stapled anastomotic line can cause diagnostic confusions, and it is not uncommon that such lesions are initially confused with rectal carcinoma. We report a case of a 38-year-old male who presented with persistent rectal bleeding some 6 months after SH performed in another hospital. Rectal and colonoscopic examinations revealed polypoid lesions at the anastomotic line. The biopsy failed to confirm malignancy, but identified cytomegalovirus (CMV) infection. The development of multiple inflammatory polypoid lesions in conjunction with CMV infection at the stapled anastomotic line has caused a diagnostic confusion, but - after exclusion of cancer - this complication was efficiently treated by CMV infection eradication combined with surgical excision of the remaining polyps due to persistence of bleeding. This case is reported to highlight late bleeding due to inflammatory polyps after SH and to increase the awareness of surgeons and gastroenterologists of this benign but somewhat common complication.

Hepatobiliary Manifestations of Sickle Cell Anemia.

Sickle cell anemia is one of the common hemoglobinopathies around the world. It results from a single change of one amino acid valine instead of glutamic acid in the hemoglobin beta change. This change leads to polymerization of the hemoglobin when the oxygen saturation is lowered, resulting in deformity of the red blood cells and microvascular occlusion. Sickle cell anemia can affect any part of the body and one of the main organs to be affected is the hepatobiliary system either directly from the sicklening process or indirectly as a result of chronic hemolysis and multiple blood transfusions. This manifests in several clinical conditions which poses diagnostic and therapeutic dilemmas to the treating physicians. These hepatobiliary manifestations will be outlined in this review.

ERCP in Patients With Sickle Cell Disease: Diagnostic and Therapeutic Dilemmas.

BACKGROUND: Cholestatic jaundice (CJ) in patients with sickle cell disease (SCD) poses diagnostic and therapeutic dilemmas. This is an evaluation of the role of ERCP in SCD. METHODS: A total of 224 SCD patients with CJ had ERCP. The indications for ERCP were based on clinical and biochemical evidence of CJ and ultrasound findings. RESULTS: The indications were: CJ only in79, CJ and dilated ducts in 103, and CJ and biliary stones in 42. The ERCP findings were: (A) For those with CJ only: ERCP was normal in 45, showed dilated ducts with no stones in 13, dilated ducts with stones in 16, normal CBD with a stone in 1; (B) For those with CJ, dilated ducts: ERCP was normal in 17, showed dilated ducts with stones in 47, dilated ducts without stones in 28, normal CBD with a stone in 1, a choledochoduodenal fistula in 2; (C) For those with CJ and duct stones: ERCP was normal in 2, showed dilated ducts with stones in 21, dilated ducts without stones in 14, normal CBD with a stone in 1. CONCLUSIONS: ERCP was unnecessary in a significant number (27%) of patients. This is especially so for those with CJ only (57%). These should be evaluated further prior to ERCP. There was also a significant number (19%) who had ES for duct dilatation without an obstruction. The reason for this dilatation is not known and the value of ES in this group needs to be investigated further.

Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy.

Roux-en-Y gastric bypass is a common surgical procedure used to treat patients with morbid obesity. One of the rare, but potentially fatal complications of gastric bypass is upper gastrointestinal bleeding, which can pose diagnostic and therapeutic dilemmas. This report describes a 39-year-old male with morbid obesity who underwent a Roux-en-Y gastric bypass. Three months postoperatively, he sustained repeated and severe upper attacks of upper gastrointestinal bleeding. He received multiple blood transfusions, and had repeated upper and lower endoscopies with no diagnostic yield. Finally, he underwent laparoscopic endoscopy which revealed a bleeding duodenal ulcer. About 5 ml of saline with adrenaline was injected, followed by electrocoagulation to seal the overlying cleft and blood vessel. He was also treated with a course of a proton pump inhibitor and given treatment for H pylori eradication with no further attacks of bleeding. Taking in consideration the difficulties in accessing the bypassed stomach endoscopically, laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in patients who had gastric bypass.

Sickle cell cholangiopathy: an endoscopic retrograde cholangiopancreatography evaluation.

AIM: To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in patients with sickle cell disease (SCD). METHODS: Two hundred and twenty four SCD patients with cholestatic jaundice (CJ) had ERCP. The indications for ERCP were based on clinical and biochemical evidence of CJ and ultrasound findings. RESULTS: Two hundred and forty ERCPs were performed. The indications for ERCP were: CJ only in 79, CJ and dilated bile ducts without stones in 103, and CJ and bile duct stones in 42. For those with CJ only, ERCP was normal in 42 (53.2%), and 13 (16.5%) had dilated bile ducts without an obstructive cause. In the remaining 22, there were bile duct stones with or without dilation. For those with CJ, dilated bile ducts and no stones, ERCP was normal in 17 (16.5%), and 28 (27.2%) had dilated bile ducts without an obstructive cause. In the remaining 58, there were bile ducts stones with or without dilation. For those with CJ and bile duct stones, ERCP was normal in two (4.8%), and 14 (33.3%) had dilated bile ducts without an obstructive cause. In the remaining 26, there were bile duct stones with or without dilatation. CONCLUSION: Considering the high frequency of biliary sludge and bile duct stones in SCD, endoscopic sphincterotomy might prove helpful in these patients.

A Case of O1 Vibrio Cholera Bacteremia and Primary Peritonitis in a Patient With Liver Cirrhosis.

Vibrio cholerae are Gram-negative bacteria that are differentiated into O1/O139 and non-O1/non-O139 serogroups depending on their ability to agglutinate with specific antiserum. In contrast to non-O1/non-0139 Vibrio cholerae, which are more prone to invade the bloodstream, Vibrio cholerae O1 is rarely the cause of bacteremia. We report a case of O1 Vibrio cholera bacteremia and primary peritonitis in a patient with liver cirrhosis. The literature on the subject is also reviewed.

Diagnostic and therapeutic ERCP in the pediatric age group.

The role and value of endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric age group is not well established, because pancreatic and biliary diseases are less common in children. This however is not the case in areas like the Eastern Province of Saudi Arabia where sickle cell disease (SCD) and other hemoglobinopathies are common, with increased frequency of cholelithiasis and choledocholithiasis. The purpose of this study was to evaluate the indications, findings, safety and therapies of ERCP in children. One hundred and twenty five children had diagnostic and/or therapeutic ERCP as part of their management at our hospital. Their medical records were reviewed for: age at diagnosis, sex, Hb electrophoresis, indication for ERCP, findings, therapy and complications. There were 77 males and 48 females. Their age at presentation ranged from 5-18 year (mean 13.25 year). The majority of them had sickle cell disease (77.6%). The indications for ERCP were: obstructive jaundice (67.2%), recurrent biliary colic with or without jaundice (10.4%), acute and chronic pancreatitis (7.2%), postoperative bile leak (2.4%), cholangitis with obstructive jaundice (2.4%), hepatitis of unknown etiology (3.2%), cirrhosis of unknown etiology (4%), thalassemia with jaundice (0.8%), hemobilia (0.8%), acute cholecystitis with jaundice (0.8%), and sickle cell disease with ulcerative colitis and obstructive jaundice (0.8%). In six children, ERCP was done following laparoscopic cholecystectomy. ERCP was carried out under sedation in 91 (72.8%) children and under general anesthesia in 34. It was successful in 121 (96.8%) children while cannulation of the Ampulla failed in four. ERCP was normal in 43 children, but eight of them showed evidence of recent stone passage and in six, there were gallstones. In the remaining children, ERCP revealed: normal CBD with stones (18 patients), dilated CBD with stones (17 patients), dilated CBD without stones (19 patients), dilated biliary tree with stones (10 patients), dilated biliary tree without stones (six patients), bile leak (two patients), dilated biliary tree with stones and choledocho-duodenal fistula (one patient), choledochal cyst (two patients), septate gallbladder (one patient), normal ERCP with multiple pancreatic cysts (one patient) and biliary stricture (one patient). The following procedures were carried out: 35 had endoscopic sphincterotomy and stone extraction, 20 had endoscopic sphincterotomy, four had CBD stenting, one underwent removal of a stent, two had insertion of a nasobiliary tube and one had biliary endoprosethesis. There was no mortality. One had bleeding from the site of sphincterotomy which stopped after adrenaline injection. Four patients (3.2%) developed transient mild pancreatitis which settled conservatively. ERCP in the pediatric age group is safe both as a diagnostic and therapeutic procedure. ERCP can provide valuable information which aid in the diagnosis of biliary and pancreatic diseases in children as well as therapy with the technical feasibility of endoscopic sphincterotomy. This is specially so in the era of laparoscopic cholecystectomy, where ERCP should be the treatment of choice in children with CBD stones who are going or have previously undergone laparoscopic cholecystectomy.