Ictericia obstructiva por neuroma de amputación de vía biliar: Reporte de caso / Obstructive ictericia by neuroma of amputation of via biliar: Case report

Los neuromas del conducto biliar se desarrollan a partir de las fibras nerviosas simpáticas y parasimpáticas que envuelven la pared de la vía biliar. Mujer de 44 años de edad con antecedente de colecistectomía convencional seis meses previos al ingreso acude a emergencia por ictericia obstructiva de 15 días de evolución. En los estudios de imagen impresiona la presencia de una masa a nivel de las vías biliares considerándose el diagnostico de una neoplasia maligna. Por los antecedentes, ausencia de marcadores tumorales se decide realizar una biopsia percutánea sin resultados concluyente, realizándose posteriormente una intervención quirúrgica con estudio anatomo-patológico compatible con neuroma de amputación de vía biliar. El neuroma de amputación a nivel de la vía biliar es un tumor infrecuente. Puede manifestarse clínicamente como una ictericia obstructiva y suele simular a un tumor maligno de las vías biliares. El manejo quirúrgico es el tratamiento definitivo.

Neuromas of the bile duct develop from the sympathetic and parasympathetic nerve fibers that surround the wall of the bile duct. A 44-year-old woman with a history of conventional cholecystectomy six months prior to hospital admission attended emergency due to obstructive jaundice that lasted 15 days. In the imaging studies, the presence of a mass at the level of the bile ducts is considered, considering the diagnosis of a malignant neoplasm. Due to the antecedents, the absence of tumor markers, it was decided to perform a percutaneous biopsy without conclusive results, performing later a surgical intervention with anatomopathological study compatible with neuroma of biliary tract amputation. The amputation neuroma at the level of the bile duct is an infrequent tumor. It can manifest clinically as obstructive jaundice and usually simulates a malignant tumor of the bile ducts. Surgical management is the definitive treatment.

[Obstructive ictericia by neuroma of amputation of via biliar. Case report]. / Ictericia obstructiva por neuroma de amputación de vía biliar. Reporte de caso.

Neuromas of the bile duct develop from the sympathetic and parasympathetic nerve fibers that surround the wall of the bile duct. A 44-year-old woman with a history of conventional cholecystectomy six months prior to hospital admission attended emergency due to obstructive jaundice that lasted 15 days. In the imaging studies, the presence of a mass at the level of the bile ducts is considered, considering the diagnosis of a malignant neoplasm. Due to the antecedents, the absence of tumor markers, it was decided to perform a percutaneous biopsy without conclusive results, performing later a surgical intervention with anatomopathological study compatible with neuroma of biliary tract amputation. The amputation neuroma at the level of the bile duct is an infrequent tumor. It can manifest clinically as obstructive jaundice and usually simulates a malignant tumor of the bile ducts. Surgical management is the definitive treatment.

FLUCTUATING JAUNDICE IN THE ADENOCARCINOMA OF THE AMPULLA OF VATER: a classic sign or an exception?

BACKGROUND: Some authors consider the fluctuating jaundice as a classic sign of the adenocarcinoma of the ampulla of Vater. OBJECTIVE: Assessing the frequency of fluctuating jaundice in their forms of its depiction in the patients with adenocarcinoma of the ampulla of Vater. METHODS: Observational and retrospective study, conducted through analyses of medical records from patients subjected to pancreatic cephalic resections between February 2008 and July 2013. The pathological examination of the surgical specimen was positive to adenocarcinoma of the ampulla of Vater. Concepts and differences on clinical and laboratory fluctuating jaundice were standardized. It was subdivided into type A and type B laboratory fluctuating jaundice. RESULTS: Twenty patients were selected. One of them always remained anicteric, 11 patients developed progressive jaundice, 2 of them developed clinical and laboratory fluctuating jaundice, 5 presented only laboratory fluctuating jaundice and one did not present significant variations on total serum bilirubin levels. Among the seven patients with fluctuating jaundice, two were classified as type A, one as type B and four were not classified due to lack information. Finally, progressive jaundice was the prevailing presentation form in these patients (11 cases). CONCLUSION: This series of cases suggested that clinical fluctuating jaundice is a uncommon signal in adenocarcinoma of the ampulla of Vater.

FLUCTUATING JAUNDICE IN THE ADENOCARCINOMA OF THE AMPULLA OF VATER: a classic sign or an exception? / Icterícia flutuante em adenocarcinoma de ampola de Vater: um sinal clássico ou uma exceção?

Background Some authors consider the fluctuating jaundice as a classic sign of the adenocarcinoma of the ampulla of Vater. Objetive Assessing the frequency of fluctuating jaundice in their forms of its depiction in the patients with adenocarcinoma of the ampulla of Vater. Methods Observational and retrospective study, conducted through analyses of medical records from patients subjected to pancreatic cephalic resections between February 2008 and July 2013. The pathological examination of the surgical specimen was positive to adenocarcinoma of the ampulla of Vater. Concepts and differences on clinical and laboratory fluctuating jaundice were standardized. It was subdivided into type A and type B laboratory fluctuating jaundice. Results Twenty patients were selected. One of them always remained anicteric, 11 patients developed progressive jaundice, 2 of them developed clinical and laboratory fluctuating jaundice, 5 presented only laboratory fluctuating jaundice and one did not present significant variations on total serum bilirubin levels. Among the seven patients with fluctuating jaundice, two were classified as type A, one as type B and four were not classified due to lack information. Finally, progressive jaundice was the prevailing presentation form in these patients (11 cases). Conclusion This series of cases suggested that clinical fluctuating jaundice is a uncommon signal in adenocarcinoma of the ampulla of Vater. .

Contexto Alguns autores consideram a icterícia flutuante como um sinal clássico do adenocarcinoma da ampola de Vater. Objetivo Determinar a frequência de icterícia flutuante em suas formas de apresentação nos pacientes portadores de adenocarcinoma de ampola de Vater. Métodos Estudo observacional e restrospectivo, realizado a partir de análise de prontuários médicos de pacientes submetidos à ressecção cefálica pancreática entre fevereiro de 2008 e julho de 2013, cujo anatomopatológico confirmou o diagnóstico de adenocarcinoma de ampola de Vater. Conceituação e diferenciação entre icterícia flutuante clínica e laboratorial foram padronizadas. Icterícia flutuante laboratorial foi dividida em tipo A e B. Resultados Vinte pacientes foram selecionados. Um deles permaneceu sempre anictérico, 11 pacientes desenvolveram icterícia progressiva, 2 desenvolveram icterícia flutuante clínica e laboratorial, 5 apresentaram apenas icterícia flutuante laboratorial e 1 não apresentou significativa variação nos níveis séricos de bilirrubina total. Entre os sete pacientes com icterícia flutuante, dois foram classificados como tipo A, um como tipo B e quatro não foram classificados devido à falta de informações. Finalmente, icterícia progressiva foi a apresentação mais prevalente nos pacientes selecionados (11 casos). Conclusão Este artigo sugere que a icterícia flutuante clínica é um sinal incomum em pacientes portadores de adenocarcinoma de ampola de Vater. .

Duodeno-biliary obstruction in Peutz-Jeghers syndrome.

BACKGROUND: Peutz-Jeghers syndrome (PJS) is a pathology with autosomal dominant inheritance characterized by the presence of hamartomatous polyposis and mucocutaneous pigmentation. We present a case report from the Hospital General of Mexico. CLINICAL CASE: We present the case of a 28-year-old male. During physical examination we noted hyperpigmented dermatosis of the oral mucosa and lips. The same condition was seen in both palms. The condition evolved with intolerance to oral feeding and progressive obstructive jaundice. Panendoscopy reported pangastric sessile polyps, as well as being pylorus passable. In the second duodenal portion occupying the region of the ampoule of Vater was a sessile polyp that deformed the region. Exit of bile was not observed through the ampoule. Ultrasound and computed tomography of the abdomen corroborated dilatation of the extrahepatic biliary tract. Two endoprostheses were placed in the bile duct by endoscopic cholangiography, with improvement of biliary obstruction. Roux-en-Y astrojejunoanastomosis was performed because of obstruction of the duodenum by polyps between the second and third portion. Jejunal enterotomy was necessary because of the presence of intraluminal injury formed by a conglomerate of polyps. The patient had a satisfactory evolution. Pathological study reported hamartomatous polyps. CONCLUSIONS: Duodenal obstruction secondary to biliary tract obstruction is a rare manifestation associated with PJS. In these cases, the treatment of choice is polyp resection using endoscopic and/or surgical approach as well as management of the biliary tract obstruction.

Endoscopic ampullectomy in a patient with a duodenal diverticulum. A challenging procedure.

A 65 year-old male was admitted to the University hospital with obstructive jaundice. Endoscopic examination revealed a grossly abnormal major ampulla, situated at the edge of a large duodenal diverticulum. Biopsy of the ampulla was positive for villous adenoma. We describe the technique utilized to successfully perform an end-bloc endoscopic resection of a major ampulla on a diverticulum.

[Suprapapilar puncture for biliary access to advanced cancer of the papilla and severe coagulopathy]. / Punción suprapapilar para acceso biliar en cáncer avanzado de papila y coagulopatía grave.

Biliary cannulation to perform endoscopic retrograde cholangiopancreatography (ERCP) may be difficult in patients with advanced papillary cancer, due to anatomical and technical reasons. Sphincterotomy may be contraindicated in severe coagulopathy. We report a recently described technique of suprapapillary puncture for biliary access with use of an Artifon's catheter for biliary access in a high-risk patient with coagulopathy and periampullary neoplasm.

Tumores periampulares: hallazgos y resultados en 21 casos consecutivos resecados / Periampullary tumors: finding and result of 21 consecutive operated cases

Los cánceres de la región periampular (CPA) han experimentado un incremento significativo en las últimas décadas, actualmente comprenden cerca del 2 por ciento de las neoplasias malignas, con una incidencia aproximada en 10 por 100.000 habitantes en USA. El objetivo de este estudio es describir y analizar los resultados obtenidos en el manejo de pacientes resecados con diagnóstico de tumor periampular (TPA) que fueron intervenidos en el Hospital Clínico Regional de Valdivia entre los años 2000 y primer trimestre de 2005. Se realizó un estudio retrospectivo en el que se revisaron fichas clínicas de pacientes en los que se diagnóstico un TPA y se incluyeron en protocolo preestablecido. Se creó una base de datos Excel y el análisis estadístico se realizó con programa Epi-Info 2002. Durante el período en estudio se intervinieron 21 casos con diagnóstico de TPA. La presentación clínica más común fue el debut como ictericia obstructiva asociado a dolor abdominal. El estudio preoperatorio se efectuó con laboratorio básico, ECO y/o TAC de abdomen. En 10 casos se realizó CPER previo a la cirugía. La pancreatogastroanastomosis se utilizó en el 95 por ciento de los casos. El aporte nutricional postoperatorio se realizó mayoritariamente por vía enteral. La morbilidad general alcanzó un 48 por ciento. Las complicaciones más frecuentes fueron las intraabdominales; dentro de éstas hubo 2 casos de fístulas pancreáticas. No se presentó mortalidad operatoria. El cáncer de ampolla fue el más frecuente en esta serie y el compromiso metastático linfonodal se presentó en un 52 por ciento. Se concluye que los CPA se presentan habitualmente con ictericia y dolor abdominal. El cáncer de ampolla es el tumor más frecuentemente resecado y la morbimortalidad de la cirugía es similar a lo reportado por experiencias de centros de alto volumen en pancreatoduodenectomía.

Obstructive jaundice secondary to bile duct involvement with Hodgkin's disease: a case report.

CONTEXT: Obstructive jaundice due to lymphoma is very rare. It may be difficult to distinguish between this condition and a large number of causes of extrahepatic bile duct obstruction, even by endoscopic retrograde cholangiography. Its prognosis is poor. Combined chemotherapy and/or radiotherapy with bile duct drainage is a therapeutic option. CASE REPORT: We describe a case of obstructive jaundice as the initial presentation of Hodgkin's disease. After chemotherapy and endoscopic bile duct stenting, it was noted that the enlarged lymph nodes, jaundice and bile duct dilation disappeared.

Obstructive jaundice secondary to bile duct involvement with Hodgkin's disease: a case report

CONTEXTO: Icterícia obstrutiva secundária a linfoma é muito rara. Em geral, a diferenciação com outras causas de obstrução biliar extra-hepática é difícil, mesmo com a colangiopancreatografia endoscópica retrógrada. Nestas condições o prognóstico é reservado. Associação de quimio, radioterapia e drenagem biliar é uma opção terapêutica a ser considerada. RELATO DE CASO: Descrevemos o caso de um paciente com icterícia obstrutiva como manifestação inicial da doença de Hodgkin. Após quimioterapia e drenagem biliar endoscópica, foi observado o desaparecimento da linfoadenomegalia, da icterícia e da dilatação da via biliar.

[Update on endoscopic management of malignant obstructive jaundice]. / Actualidades en el manejo endoscópico de la ictericia obstructiva maligna.

The diagnosis of bilio-pancreatic diseases is carried out when patients present symptoms of biliary obstruction. The majority of these patients cannot receive curative treatment at the time of the diagnosis. Laboratory tests can differentiate between intra- or extra-hepatic obstruction, and the different imaging techniques will establish the cause and degree of disease extension. Endoscopic cholangiography can confirm the tumor's etiology with a biopsy, cytology or aspiration at the level of the stenosis. Palliative endoscopic treatment offers good results. The decision of placing a plastic or metallic stent will depend on the probable survival rate that the patient has. In tumors in the hila a previous magnetic resonance cholangiography plays a fundamental role in the therapeutic decision.

Malignant hilar and perihilar biliary obstruction: use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions.

PURPOSE: To determine the usefulness of magnetic resonance (MR) cholangiography in defining the extent of biliary ductal involvement in patients with malignant hilar and perihilar biliary obstruction and to evaluate whether findings at MR cholangiography alone are sufficient to plan percutaneous interventions in these patients. MATERIALS AND METHODS: Twenty-nine patients with malignant hilar and perihilar biliary obstruction were examined with MR cholangiography. Two radiologists evaluated MR images and determined the extent of biliary ductal involvement. A hypothetical plan for biliary drainage was established prior to any intervention. All patients underwent percutaneous cholangiography, and 27 of 29 patients also underwent biliary drainage and/or stent placement within 7 days after MR cholangiography. By using direct cholangiography as the standard of reference, the usefulness of MR cholangiography in defining the extent of biliary ductal involvement was determined. The type of drainage performed was compared with the type that had been anticipated at MR cholangiography. RESULTS: MR cholangiography was adequate in helping predict the extent of biliary ductal involvement in 28 (96%) of 29 patients and led to underestimation of the extent of the disease in one patient. The therapeutic plan anticipated with MR cholangiography matched the one actually used in 24 (83%) of 29 patients. CONCLUSION: The high accuracy of MR cholangiography for defining extent of ductal involvement in patients with malignant hilar and perihilar obstruction allows adequate planning of percutaneous interventions in a majority of patients.

Cáncer de la ampolla de Vater: resultados postoperatorios y sobrevida / Cancer of the ampulla of Vater: postoperative study and survival

Se presenta nuestra experiencia en el manejo de 27 ampulomas tratados durante un período de 9 años (1990-1999). Son hombres y 16 hombres y 11 mujeres con edad promedio de 54 años (27-74). Se resecó 21 pacientes (77,77 por ciento), en ocaciones con técnicas de duodenopancreatectomía modificada y un paciente, con cáncer gástrico sincrónico, con técnica de Whipple clásico. Se produjo un 17 por ciento de complicaciones quirúrgicas, una de ellas fue una fístula pancreática (4,76 por ciento), un 28,57 por ciento presentó retardo del vaciamiento gástrico y hubo sólo un fallecido por complicaciones médicas (4,76 por ciento). La sobrevida actuarial a 5 años es de 47 por ciento para toda la serie y 61 por ciento para el grupo de los resecados

Valor de la colangiografía por resonancia magnética en la obstrucción biliar benigna y maligna / MR cholangiography in bening and malign biliary obstruction

El objetivo de este trabajo fue evaluar la sensibilidad, especificidad y valor predictivo positivo y negativo de la colangiografía por Resonancia Magnética (MRCP) en pacientes con patología biliar obstructiva benigna y maligna. Se estudiaron por MRCP 106 pacientes con sospecha de patología biliar en secuencias 3D turbo SPIN-ECO T2 con técnica de supresión grasa: 49 presentaron obstrucción biliar, de los cuales 48 fueron correctamente diagnosticados, con una sensibilidad del 92 por ciento, especificidad del 90 por ciento, VPP del 94 por ciento y VPN del 88 por ciento. Concluimos que la MRCP es un nuevo procedimiento diagnóstico no invasivo que muestra alta sensibilidad y especificidad en el diagnóstico de lesiones benignas y malignas del árbol biliopancreático (AU)