RECURRENT PYOGENIC CHOLANGITIS
|
|
- Kevin Watson
- 5 years ago
- Views:
Transcription
1 RECURRENT PYOGENIC CHOLANGITIS Resident(s): Evan Raff, MD MHA Attending(s): Narasimham Dasika, MD Program/Dept(s): University of Michigan Health System, Department of Radiology
2 CHIEF COMPLAINT & HPI Chief Complaint and/or reason for consultation Itching, jaundice, fever, and abdominal pain for 1 week History of Present Illness 44-year-old Chinese woman with history of recurrent episodes of cholangitis who presents with one week history of increased systemic itching and yellowing in her eyes. She reports sharp midepigastric pain that lasted for about 30 minutes starting 1 day ago with subjective fevers, chills and sweats. She also reports dark urine, light colored stools and noticed her skin was yellow. She also has intermittent nausea without vomiting. Patient reports several year history of intermittent fevers and chills without abdominal pain, nausea or vomiting which began during pregnancy. Work up included several ERCPs with findings interpreted as primary sclerosing cholangitis.
3 RELEVANT HISTORY Past Medical History Multiple episodes of cholangitis. Reported history of parasitic infection in infancy. Past Surgical History None Family & Social History Born in China and moved to USA in the late 1970s. No tobacco or drug use, rare alcohol. Review of Systems Negative unless as stated above. Medications: None Allergies: NKDA
4 DIAGNOSTIC WORKUP Physical Exam T 98.4 BP 111/62 HR 96 RR 18 O2 sat 96% on RA General: Well-appearing, lying in bed, NAD Eyes: Mild scleral icterus GI/ABD: Soft, nondistended, mild tenderness to palpation in the RUQ/epigastric region w/o rebound/guarding, normoactive bowel sounds. Ext: No LE edema, all 4 extremities w/w/p
5 DIAGNOSTIC WORKUP Laboratory Data WBC 17.7, AST 74, ALT 118, Alk phos 830, Tbil 3.0. Non-Invasive Imaging Ultrasound: Intrahepatic ductal dilation filled with echogenic material suspected to be stones. MRCP: Severe stricturing of the central intrahepatic ducts and large intrahepatic stone burden. Transient periductal arterial hyperenhancement likely reflects cholangitis.
6 QUESTION SLIDE 1) Recommended first line imaging for patients with suspected recurrent pyogenic cholangitis: A: Contrast enhanced CT. B: Ultrasound. C: MRCP. D: ERCP.
7 CORRECT! CONTINUE WITH CASE 1) Recommended first line imaging investigation for patients with suspected recurrent pyogenic cholangitis: A: Contrast enhanced CT. Provides better spatial resolution than ultrasound, but with radiation. Similar ability to detect stones, pneumobilia and masses. Enhancement of biliary mucosa can indicate active cholangitis. B: Ultrasound. Quick and cost effective, ultrasound can demonstrate the general features of RPC including intrahepatic calculi (identified in up to 90% of patients), pneumobilia, ductal dilatation and related complications including hepatic masses (e.g., abscess, cholangiocarcinoma). (Heffernan et al., AJR 2009) C: MRCP. Expensive but with ability to characterize ducts proximal to an obstruction or tight stenosis better than ERCP. No risk of aggravating biliary sepsis. Improved sequence speed reduce motion artifacts. D: ERCP. Allows for stone removal, cytologic but has risk for aggravation/development of biliary sepsis. Previously the gold standard with high spatial resolution, MRCP is preferred for given noninvasive nature.
8 SORRY, THAT S INCORRECT! CONTINUE WITH CASE 1) Recommended first line imaging investigation for patients with suspected recurrent pyogenic cholangitis: A: Contrast enhanced CT. Provides better spatial resolution than ultrasound, but with radiation. Similar ability to detect stones, pneumobilia and masses. Enhancement of biliary mucosa can indicate active cholangitis. B: Ultrasound. Quick and cost effective, ultrasound can demonstrate the general features of RPC including intrahepatic calculi (identified in up to 90% of patients), pneumobilia, ductal dilatation and related complications including hepatic masses (e.g., abscess, cholangiocarcinoma). (Heffernan et al., AJR 2009) C: MRCP. Expensive but with ability to characterize ducts proximal to an obstruction or tight stenosis better than ERCP. No risk of aggravating biliary sepsis. Improved sequence speed reduce motion artifacts. D: ERCP. Allows for stone removal, cytologic but has risk for aggravation/development of biliary sepsis. Previously the gold standard with high spatial resolution, MRCP is preferred for given noninvasive nature.
9 ABDOMINAL US Abdominal US: Several shadowing echogenic foci (arrow) are present in the central biliary system compatible with intrahepatic biliary stone with diffuse biliary intrahepatic dilatation.
10 CT ABDOMEN PELVIS CT Abdomen Pelvis: Marked central intrahepatic biliary dilatation. Several foci of high attenuation are present compatible with stones (not seen on these images).
11 MRCP MRCP images demonstrate multifocal biliary strictures and dilatation with intrahepatic filling defects (arrow) compatible with stones. Volume rendered images (right) demonstrate diffuse intrahepatic biliary dilatation.
12 ERCP ERCP image shows diffuse intrahepatic duct dilatation with multiple stones (arrow) and biliary sludge
13 DIAGNOSIS Recurrent pyogenic cholangitis (RPC) causing secondary sclerosing cholangitis Differential Diagnosis Primary sclerosing cholangitis Peribiliary cysts Hydatid disease Peripheral cholangiocarcinoma Caroli s disease AIDS cholangiopathy
14 QUESTION SLIDE 2) Complications of recurrent pyogenic cholangitis include A: Cholangiocarcinoma B: Biloma C: Portal vein thrombosis D: Cirrhosis E: All of the above
15 CORRECT! 2) Complications of recurrent pyogenic cholangitis include A: Cholangiocarcinoma B: Biloma C: Portal vein thrombosis D: Cirrhosis E: All of the above. Patients with severe RPC are at risk for all of the above. These complications should be monitored with serial imaging and cytology examinations. CONTINUE WITH CASE
16 SORRY, THAT S INCORRECT! 2) Complications of recurrent pyogenic cholangitis include A: Cholangiocarcinoma B: Biloma C: Portal vein thrombosis D: Cirrhosis E: All of the above. Patients with severe RPC are at risk for all of the above. These complications should be monitored with serial imaging and cytology examinations. CONTINUE WITH CASE
17 QUESTION SLIDE 3) Benefit of MRCP over ERCP in the evaluation of RPC includes: 1. Decreased risk of biliary sepsis 2. Improved spatial resolution 3. Allows for stone removal and cytological analysis 4. Ability to visualize ducts distal to central obstruction A: 2 and 3 B: 1 and 3 C: 1 and 4 D: 2 and 4
18 CORRECT! 3) Benefits of MRCP over ERCP in the evaluation of RPC include: A: 2 and 3 B: 1 and 3 C: 1 and 4. MRCP allows for improved visualization of ducts distal to obstructions but has a lower spatial resolution than ERCP. ERCP may be used for stone removal, analysis and cytology but results in increased risk for aggravation of bacteremia. D: 2 and 4 CONTINUE WITH CASE
19 SORRY, THAT S INCORRECT! 3) Benefits of MRCP over ERCP in the evaluation of RPC include: A: 2 and 3 B: 1 and 3 C: 1 and 4. MRCP allows for improved visualization of ducts distal to obstructions but has a lower spatial resolution than ERCP. ERCP may be used for stone removal, analysis and cytology but results in increased risk for aggravation of bacteremia. D: 2 and 4 CONTINUE WITH CASE
20 INTERVENTION Bilateral PTC tube placement for recurrent cholangitis with extensive intrahepatic stone burden. Biliary culture: Positive for Klebsiella, Enterococci and Pseduomonas. Dilatation of the bilateral PTC tract with placement of 20 Fr choledochoscope sheaths bilaterally. Choledochoscopy and biliary stone removal of extensive stone burden in the right and left intrahepatic ducts and exchange of PTC tubes.
21 INITIAL PTC PLACEMENT The biliary system was accessed under ultrasound guidance using a 22 gauge Chiba needle through which a wire was passed. Fluoroscopic images demonstrate moderate to severe bilateral central and intrahepatic ductal dilatation with associated central and intrahepatic biliary duct strictures. In addition, there are multiple filling defects seen throughout the bilateral biliary ducts, consistent with sludge, debris, and stones.
22 CHOLEDOCHOSCOPY (6 weeks post presentation) Fluoroscopic images show placement of bilateral Amplatz superstiff guidewires through existing biliary drainage tube tracts and dilatation of PTC tracts using two kissing 8 x 4 mm balloons. 20 Fr peel away sheaths were placed through which a 16.5 Fr choledochoscope was advanced into the right and left hepatic ducts.
23 CHOLEDOCHOSCOPY (6 weeks post presentation) Extensive right and left intrahepatic biliary calculi were seen involving almost all the segmental ducts including the common hepatic duct and CBD. Small casts and debris were removed by scope and Nitinol Zero tip 4 wire basket. Large CBD stone was fragmented using electrohydraulic lithotripsy. Bilateral 14Fr pigtail PTC tubes with additional sideholes were placed for additional external and internal drainage.
24 CLINICAL FOLLOW UP Patient has returned for multiple PTC exchanges with balloon clearance of CBD, right and left main hepatic ducts, and segmental/subsegmental ducts Labs: Stone analysis: calcium bilirubinate Repeat common bile duct/hepatic duct brushing cytology negative for malignant cells Course has been complicated by recurrent episodes of cholangitis with bile cultures positive for Klebsiella, Enterococci and Pseduomonas. Patient is maintained on outpatient oral antibiotics (augmentin, PCN, & Cipro). Given recurrent nature of disease, the patient was referred for surgical consultation for choledochojejunostomy
25 QUESTION SLIDE 4) Treatment option for localized lobar disease when atrophy has occurred includes: A: Segmental hepatic resection B: Orthotopic liver transplant C: Endoscopic intervention D: Biliary bypass
26 CORRECT! 4) Treatment option which should be considered for localized RPC: A: Segmental hepatic resection. May be considered when calculi are isolated to the a single lobe generally after atrophy has occurred. This can reduce the risk for hepatic abscess formation and cholangiocarcinoma. B: Orthotopic liver transplant C: Endoscopic intervention D: Biliary bypass CONTINUE WITH CASE
27 SORRY, THAT S INCORRECT! 4) Treatment option which should be considered for localized RPC: A: Segmental hepatic resection. May be considered when calculi are isolated to the a single lobe generally after atrophy has occurred. This can reduce the risk for hepatic abscess formation and cholangiocarcinoma. B: Orthotopic liver transplant C: Endoscopic intervention D: Biliary bypass CONTINUE WITH CASE
28 SUMMARY & TEACHING POINTS Pathogenesis: Found almost exclusively in East and Southeast Asia where infection by parasitic helminths (Ascaris) or liver flukes (Clonorchis, Opisthorchis, and Metorchis) is common. Parasites induce biliary epithelial damage/fibrosis leading to stricturing and secondary infection by enteric bacteria (commonly E. coli, Klebsiella, Pseudomonas, and Proteus) Bacteria-produced gluconidases lead to pigment stone formation; low protein intake or abnormal phospholipid metabolism may reduce natural inhibition of glucoronidases. Presentation Fever, RUQ pain, leukocytosis, elevated alkaline phosphatase and bilirubin Incidence in Asia decreasing due to improved nutritional standards, but prevalence in the West increasing due to migration from endemic areas Recurrent episodes of cholangitis lead to secondary biliary sclerosis and eventually biliary cirrhosis and portal hypertension in later stages
29 SUMMARY & TEACHING POINTS Diagnosis: Combination of clinical, laboratory and imaging characteristics History of LFTs, stool O&P, serum ELISA, biliary cytology Initial evaluation by ultrasound, followed by ERCP/MRCP Treatment: Requires repeated multidisciplinary approach Antibiotic therapy for recurrent episodes; equivocal evidence for ursodial therapy Biliary drainage and stone removal via ERCP and PTC Surgical hepatico-jejunostomy or lobectomy for advanced or isolated left lobe disease Complications Liver abscess formation (20%) and risk for septic emboli Secondary biliary cirrhosis, portal vein thrombosis Biloma Cholangiocarcinoma (1.5-11%) and inflammatory pseudotumor
30 REFERENCES & FURTHER READING Afagh, A, et al: Radiologic findings in recurrent pyogenic cholangitis. The Journal of Emergency Medicine, Vol. 26, No. 3, pp , 2004 Al-Sukhni, W, et al: Recurrent Pyogenic Cholangitis with Hepatolithiasis The Role of Surgical Therapy in North America. J Gastrointest Surg 12: , 2008 Cheung, MT, et al: Liver Resection for Intrahepatic Stones. Arch Surg.140: , 2005 Harris, HW, et al: Recurrent Pyogenic Cholangitis. American Journal of Surgery. 176:35-37, 1998 Heffernan EJ et al: Recurrent pyogenic cholangitis: from imaging to intervention. AJR Am J Roentgenol. 192(1):W28-35, 2009 Jain M et al: MRCP findings in recurrent pyogenic cholangitis. Eur J Radiol. 66(1):79-83, 2008 Jeyarajah, DR: Recurrent Pyogenic Cholangitis Current Treatment Options in Gastroenterology. 7:91 98, 2004 Kim JH et al: CT findings of cholangiocarcinoma associated with recurrent pyogenic cholangitis. AJR Am J Roentgenol. 187(6):1571-7, 2006 Lee, KF et al: Outcome of surgical treatment for recurrent pyogenic cholangitis: a single-centre study. HPB 11, 75 80, 2009 Lee WJ et al: Radiologic spectrum of cholangiocarcinoma: emphasis on unusual manifestations and differential diagnoses. Radiographics. 21 Spec No:S97-S116, 2001 Lo CM et al: The changing epidemiology of recurrent pyogenic cholangitis. Hong Kong Med J. 3(3): , 1997 Mori, T et al: Management of intrahepatic stones. Best Practice & Research Clinical Gastroenterology 20:6, 1117e1137, 2006 Nguyen, T et al: Recurrent Pyogenic Cholangitis. Dig Dis Sci (2010) 55:8 10 Park MS et al: Recurrent pyogenic cholangitis: comparison between MR cholangiography and direct cholangiography. Radiology. 220(3):677-82, 2001 Shoda, J et al: Molecular Pathogenesis of Hepatolithiasis A Type of Low Phospholipid-Associated Cholelithiasis. Frontiers in Bioscience 11, , 2006 Sperling RM et al: Recurrent pyogenic cholangitis in Asian immigrants to the United States: natural history and role of therapeutic ERCP. Dig Dis Sci. 42(4):865-71, 1997 Tsui WM et al: Hepatolithiasis and the syndrome of recurrent pyogenic cholangitis: clinical, radiologic, and pathologic features. Semin Liver Dis. 31(1):33-48, 2011
MAKING CONNECTIONS. Los Angeles Medical Center
MAKING CONNECTIONS Los Angeles Medical Center Resident: Chris Molloy, MD Fellow: Christian Coroian, MD, MBA Attending: Tina Hardley, MD Program/Dept(s): Los Angeles Medical Center CHIEF COMPLAINT & HPI
More informationCholangiocarcinoma (Bile Duct Cancer)
Cholangiocarcinoma (Bile Duct Cancer) The Bile Duct System (Biliary Tract) A network of bile ducts (tubes) connects the liver and the gallbladder to the small intestine. This network begins in the liver
More informationImaging of liver and pancreas
Imaging of liver and pancreas.. Disease of the liver Focal liver disease Diffusion liver disease Focal liver disease Benign Cyst Abscess Hemangioma FNH Hepatic adenoma HCC Malignant Fibrolamellar carcinoma
More informationPersonal Profile. Name: 劉 XX Gender: Female Age: 53-y/o Past history. Hepatitis B carrier
Personal Profile Name: 劉 XX Gender: Female Age: 53-y/o Past history Hepatitis B carrier Chief complaint Fever on and off for 2 days Present illness 94.10.14 Sudden onset of epigastric pain 94.10.15 Fever
More informationManagement of Cholangiocarcinoma. Roseanna Lee, MD PGY-5 Kings County Hospital
Management of Cholangiocarcinoma Roseanna Lee, MD PGY-5 Kings County Hospital Case Presentation 37 year old male from Yemen presented with 2 week history of epigastric pain, anorexia, jaundice and puritis.
More informationLutheran Medical Center. Daniel H. Hunt, M.D. June 10 th, 2005
Lutheran Medical Center Daniel H. Hunt, M.D. June 10 th, 2005 History xx y.o. pt with primary CBD stones s/p ERCP xx months earlier for attempted stone extraction resulting in post ERCP pancreatitis. Patient
More informationA Local Experience in the Management of Recurrent Pyogenic Cholangitis (Oriental Cholangitis)
Bahrain Medical Bulletin, Vol.24, No.1, March 2002 A Local Experience in the Management of Recurrent Pyogenic Cholangitis (Oriental Cholangitis) Suhair Khalifa Al-Saad, CABS, FRCSI* Mohammed Khurshid Alam,
More informationHilar cholangiocarcinoma. Frank Wessels, Maarten van Leeuwen, UMCU utrecht
Hilar cholangiocarcinoma Frank Wessels, Maarten van Leeuwen, UMCU utrecht Content Anatomy Biliary strictures (Hilar) Cholangiocarcinoom Staging Biliary tract 1 st order Ductus hepatica dextra Ductus hepaticus
More informationCase 1- B.N. 66 yr old F with PMHx of breast cancer s/ p mastectomy, HTN, DM presented with dysphagia to solids and liquids.
Case 1- B.N 66 yr old F with PMHx of breast cancer s/ p mastectomy, HTN, DM presented with dysphagia to solids and liquids. Reports retching to clear esophagus. Case 1- B.N EGD: Stricture in the distal
More informationCholangiocarcinoma: Radiologic evaluation and interventions
November 2014 Cholangiocarcinoma: Radiologic evaluation and interventions Colin Nevins, Harvard Medical School Year III Agenda Initial course and work-up Endoscopic retrograde cholangiopancreatography
More informationManagement of Gallbladder Disease
Management of Gallbladder Disease Steven B. Johnson, MD, FACS, FCCM Professor and Chairman, Department of Surgery Program Director, Phoenix Integrated Surgical Residency University of Arizona College of
More informationPrimary Sclerosing Cholangitis and Cholestatic liver diseases. Ahsan M Bhatti MD, FACP Bhatti Gastroenterology Consultants
Primary Sclerosing Cholangitis and Cholestatic liver diseases Ahsan M Bhatti MD, FACP Bhatti Gastroenterology Consultants I have nothing to disclose Educational Objectives What is PSC? Understand the cholestatic
More informationPercutaneous Removal of Biliary Stone from Anomalous Right Hepatic Duct
Percutaneous Removal of Biliary Stone from Anomalous Right Hepatic Duct Pages with reference to book, From 94 To 96 Tanveer ul Haq, Mohammed Younus Sheikh, Changes Khan Jadun, M.N. Ahmad, Yousuf H. Husen
More informationlaparoscopic cholecystectomy
Combined percutaneous and endoscopic approach in management of dropped gallstones following laparoscopic cholecystectomy John S.F. Shum 1*, K.H. Fung 1, George P.C. Yang 2, Chung Ngai Tang 2, Michael K.W.
More informationPictorial review of Benign Biliary tract abnormality on MRCP/MRI Liver with Endoscopic (including splyglass) and Endoscopic Ultrasound correlation
Pictorial review of Benign Biliary tract abnormality on MRCP/MRI Liver with Endoscopic (including splyglass) and Endoscopic Ultrasound correlation Poster No.: C-2617 Congress: ECR 2015 Type: Educational
More informationBiliary tree dilation - and now what?
Biliary tree dilation - and now what? Poster No.: C-1767 Congress: ECR 2012 Type: Educational Exhibit Authors: I. Ferreira, A. B. Ramos, S. Magalhães, M. Certo; Porto/PT Keywords: Pathology, Diagnostic
More informationCHOLANGIOCARCINOMA (CCA)
CHOLANGIOCARCINOMA (CCA) Deepak Hariharan MD (Research), FRCS, Locum Consultant HPB Surgeon AIM Outline essential facts & principles Present 4 cases Discuss Challenges /Controversies INTRODUCTION Most
More informationColangitis Esclerosante Primaria: Manejo Clínico y Endoscópico
Colangitis Esclerosante Primaria: Manejo Clínico y Endoscópico Andrés Cárdenas, MD, MMSc, PhD, AGAF, FAASLD GI / Liver Unit, Hospital Clinic Institut de Malalties Digestives i Metaboliques Associate Professor
More informationTratamiento endoscópico de la CEP. En quien como y cuando?
Tratamiento endoscópico de la CEP. En quien como y cuando? Andrés Cárdenas, MD, MMSc, PhD, AGAF, FAASLD GI / Liver Unit, Hospital Clinic Institut de Malalties Digestives i Metaboliques University of Barcelona
More informationERCP / PTC Surgical Laparoscopic vs open Timing and order of approach
Choledocholithiasis Which Approach and When? Lygia Stewart, MD University of California, San Francisco 2010 Naffziger Post-Graduate Course Clinical Manifestations of Choledocholithiasis Asymptomatic (no
More informationJaundice. Agnieszka Dobrowolska- Zachwieja, MD, PhD
Jaundice Agnieszka Dobrowolska- Zachwieja, MD, PhD Jaundice definition Jaundice, as in the French jaune, refers to the yellow discoloration of the skin. It arises from the abnormal accumulation of bilirubin
More informationMaking ERCP Easy: Tips From A Master
Making ERCP Easy: Tips From A Master Raj J. Shah, M.D., FASGE Associate Professor of Medicine University of Colorado School of Medicine Co-Director, Endoscopy Director, Pancreaticobiliary Endoscopy Services
More informationApproach to the Biliary Stricture
Approach to the Biliary Stricture ACG Eastern Postgraduate Course Washington DC June 8, 2014 Steven A. Edmundowicz MD FASGE Chief of Endoscopy Division of Gastroenterology Professor of Medicine Disclosures
More informationEvaluation and Management of Refractory Biliary Stricture. J. David Horwhat, MD, FACG Director of Endoscopy Lancaster Gastroenterology, Inc.
Evaluation and Management of Refractory Biliary Stricture J. David Horwhat, MD, FACG Director of Endoscopy Lancaster Gastroenterology, Inc Outline What defines a refractory biliary stricture Endoscopic
More informationAn unusual source of right upper quadrant pain
Originally Posted: Month, 00, 20xx An unusual source of right upper quadrant pain Resident(s): Ashish R. Vyas MD (PGY-V), Dominic T. Semaan M.D., J.D. (PGY-V) Attending(s): Dr. Denis Lincoln Program/Dept(s):
More informationMANAGEMENT OF PYOGENIC LIVER ABSCESS BOYOUNG SONG, M.D. SUNY DOWNSTATE SURGERY 11/7/13
MANAGEMENT OF PYOGENIC LIVER ABSCESS BOYOUNG SONG, M.D. SUNY DOWNSTATE SURGERY 11/7/13 CASE THE PATIENT IS A 79 YEAR OLD MALE WITH 3 DAY HISTORY OF LOWER ABDOMINAL PAIN, NAUSEA WITHOUT VOMITING, CHILLS
More informationOriginal Policy Date 12:2013
MP 6.01.30 Magnetic Resonance Cholangiopancreatography Medical Policy Section Radiology Is12:2013sue 3:2005 Original Policy Date 12:2013 Last Review Status/Date 12:2013 Return to Medical Policy Index Disclaimer
More informationEndoscopic Management of Biliary Strictures. Sammy Ho, MD Director of Pancreaticobiliary Services and Endoscopic Ultrasound Montefiore Medical Center
Endoscopic Management of Biliary Strictures Sammy Ho, MD Director of Pancreaticobiliary Services and Endoscopic Ultrasound Montefiore Medical Center Malignant Biliary Strictures Etiologies: Pancreatic
More informationResident, PGY1 David Geffen School of Medicine at UCLA. Los Angeles Society of Pathology Resident and Fellow Symposium 2013
Resident, PGY1 David Geffen School of Medicine at UCLA Los Angeles Society of Pathology Resident and Fellow Symposium 2013 85 year old female with past medical history including paroxysmal atrial fibrillation,
More informationA Review of Liver Function Tests. James Gray Gastroenterology Vancouver
A Review of Liver Function Tests James Gray Gastroenterology Vancouver Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted
More informationNoncalculous Biliary Disease Dean Abramson, M.D. Gastroenterologists, P.C. Cedar Rapids. Cholestasis
Noncalculous Biliary Disease Dean Abramson, M.D. Gastroenterologists, P.C. Cedar Rapids Cholestasis Biochemical hallmark Impaired bile flow from liver to small intestine Alkaline phosphatase is primary
More informationCase 7729 Child with choledochal cyst presenting with episodes of vomitting and jaundice
Case 7729 Child with choledochal cyst presenting with episodes of vomitting and jaundice dos Santos R 1, Almeida J 1, Mendes PP 2, Pereira S 3, Borges C 3, Soares E 4. 1) Radiology resident, 2) Radiology
More informationOverview of PSC Making the Diagnosis
Overview of PSC Making the Diagnosis Tamar Taddei, MD Assistant Professor of Medicine Yale University School of Medicine Overview Definition Epidemiology Diagnosis Modes of presentation Associated diseases
More informationPost-operative complications following hepatobiliary surgery: imaging findings and current radiological treatment options
Post-operative complications following hepatobiliary surgery: imaging findings and current radiological treatment options Poster No.: C-1501 Congress: ECR 2015 Type: Educational Exhibit Authors: A. Hadjivassiliou,
More informationBile Duct Injury during Lap Chole. Bile Duct Injury during cholecystectomy TOPICS. 1. Prevalence, mechanisms, prevention and diagnosis
Bile Duct Injury during cholecystectomy Catherine HUBERT Jean-Fran François GIGOT Benoît t NAVEZ Division of Hepato-Biliary Biliary-Pancreatic Surgery Department of Abdominal Surgery and Transplantation
More informationCBD stones & strictures (Obstructive jaundice)
1 CBD stones & strictures (Obstructive jaundice) Dr. Muhammad Shamim FCPS (Pak), FACS (USA), FICS (USA), MHPE (Nl & Eg) Assistant Professor, Dept. of Surgery College of Medicine, Prince Sattam bin Abdulaziz
More informationA patient with an unusual congenital anomaly of the pancreaticobiliary tree
A patient with an unusual congenital anomaly of the pancreaticobiliary tree Thomas Hocker, HMS IV BIDMC Core Radiology Case Presentation September 17, 2007 Review of Normal Pancreaticobiliary Tract Anatomy
More informationROLE OF RADIOLOGY IN INVESTIGATION OF JAUNDICE
ROLE OF RADIOLOGY IN INVESTIGATION OF JAUNDICE Dr. Sohan kumar sah *, Dr. Liu Sibin, Dr. sumendra raj pandey, Dr. Prakashmaan shah, Dr. Gaurishankar pandit, Dr. Suraj kurmi and Dr. Sanjay kumar jaiswal
More informationVesalius SCALpel : Biliary (see also: biliary/pancreatic folios) Physiology
Vesalius SCALpel : Biliary (see also: biliary/pancreatic folios) Physiology 95% of bile acids reabsorbed; colic and chenodeoxycolic primary bile acids cholecystokinin (CCK) major stimulus of gallbladder
More information7/11/2017. We re gonna help a lot of people today. Biliary/Pancreatic Endoscopy. AGS July 1-2, Kenneth M. Sigman, MD
Biliary/Pancreatic Endoscopy AGS July 1-2, 2017 Kenneth M. Sigman, MD We re gonna help a lot of people today 1 2 3 4 Cannulation It all starts with cannulation Double Wire Cannulation Difficult cannulations
More informationTogether, putting patients first
The Role of a Gastroenterologist in the Diagnosis and Management of Pancreatic Cancer Sarah Jowett, Consultant Gastroenterologist Bradford Teaching Hospitals Trust Leeds Regional Study Day, 12 September
More informationThe role of ERCP in chronic pancreatitis
The role of ERCP in chronic pancreatitis Marianna Arvanitakis Erasme University Hospital, ULB, Brussels, Belgium 10 th Nottingham Endoscopy Masterclass SPEAKER DECLARATIONS This presenter has the following
More informationDisclosures. Extra-hepatic Biliary Disease and the Pancreas. Objectives. Pancreatitis 10/3/2018. No relevant financial disclosures to report
Extra-hepatic Biliary Disease and the Pancreas Disclosures No relevant financial disclosures to report Jeffrey Coughenour MD FACS Clinical Associate Professor of Surgery and Emergency Medicine Division
More informationApproach to the Patient with Liver Disease
Approach to the Patient with Liver Disease Diagnosis of liver disease Careful history taking Physical examination Laboratory tests Radiologic examination and imaging studies Liver biopsy Liver diseases
More informationSUNY Downstate Medical Center Kings County Hospital
Management of Choledocholithiasis SUNY Downstate Medical Center Kings County Hospital Department of Surgery Grand Rounds Kiyanda Baldwin October 22, 2009 Case Presentation 43 y/o F c/o jaundice x 3 days
More informationENDOSCOPIC TREATMENT OF A BILE DUCT
HPB Surgery, 1990, Vol. 3, pp. 67-71 Reprints available directly from the publisher Photocopying permitted by license only 1990 Harwood Academic Publishers GmbH Printed in the United Kingdom CASE REPORT
More informationThe campaign on laboratory: focus on Gallstone Disease and ERCP
The campaign on laboratory: focus on Gallstone Disease and ERCP Mauro Giuliani, MD, Specialist in Visceral Surgery, Vice Head Physician, Surgical Ward, Ospedale Regionale di Locarno Alberto Fasoli, MD,
More informationClassification of choledochal cyst with MR cholangiopancreatography in children and infants: special reference to type Ic and type IVa cyst
Classification of choledochal cyst with MR cholangiopancreatography in children and infants: special reference to type Ic and type IVa cyst Poster No.: C-1333 Congress: ECR 2011 Type: Educational Exhibit
More informationCholelithiasis & cholecystitis
1 Cholelithiasis & cholecystitis Dr. Muhammad Shamim FCPS (Pak), FACS (USA), FICS (USA) Assistant Professor, Dept. of Surgery College of Medicine, Prince Sattam bin Abdulaziz University Email: surgeon.shamim@gmail.com
More informationR.Sotoudehmanesh, MD Professor of Gastroenterology Digestive Disease Research Institute Tehran University of Medical Sciences Pancreatobiliary
R.Sotoudehmanesh, MD Professor of Gastroenterology Digestive Disease Research Institute Tehran University of Medical Sciences Pancreatobiliary /Advanced Endoscopy group Most common biliary malignancy and
More informationJAUNDICE. Zdeněk Fryšák 3rd Clinic of Internal Medicine Nephrology-Rheumatology-Endocrinology Faculty Hospital Olomouc
JAUNDICE Zdeněk Fryšák 3rd Clinic of Internal Medicine Nephrology-Rheumatology-Endocrinology Faculty Hospital Olomouc Definition of Jaundice Icterus A yellowish staining of the skin, sclerae and deeper
More informationA CASE REPORT OF SPONTANEOUS BILOMA - AN ENIGMATIC SURGICAL PROBLEM
A CASE REPORT OF SPONTANEOUS BILOMA - AN ENIGMATIC SURGICAL PROBLEM *Sumanta Kumar Ghosh and Biswajit Mukherjee ESIC Medical College, Joka, Kolkata, India *Author for Correspondence ABSTRACT Occurrence
More informationUSMLE and COMLEX II. CE / CK Review. General Surgery. 1. Northwestern Medical Review
USMLE and COMLEX II CE / CK Review General Surgery 1. Northwestern Medical Review Northwestern Medical Review www.northwesternmedicalreview.com Lansing, Michigan 2014-2015 Acute Abdomen 1. Your patient
More informationSurgical Management of Chronic Pancreatitis VERENA LIU, MD KINGS COUNTY HOSPITAL CENTER SURGERY GRAND ROUNDS 4/1/2013
Surgical Management of Chronic Pancreatitis VERENA LIU, MD KINGS COUNTY HOSPITAL CENTER SURGERY GRAND ROUNDS 4/1/2013 Case Report 42F with h/o chronic pancreatitis due to alcohol use with chronic upper
More informationBiliary Anatomy in Living-related Liver Transplantation
The 5th IHPBA Congress - Istanbul Biliary Anatomy in Living-related Liver Transplantation biliary trees hilar plate Assessment for Vascular Anatomy 1. 3DCT portal vein hepatic vein hepatic artery 2. No
More informationBiliary Atresia. Karen F. Murray, MD Professor of Pediatrics Director, Hepatobiliary Program Seattle Children s
Biliary Atresia Karen F. Murray, MD Professor of Pediatrics Director, Hepatobiliary Program Seattle Children s Biliary Atresia Incidence: 1/8,000-15,000 live births Girls > boys 1.5:1 The most common cause
More informationAutoimmune Hepatobiliary Diseases PROF. DR. SABEHA ALBAYATI CABM,FRCP
Autoimmune Hepatobiliary Diseases PROF. DR. SABEHA ALBAYATI CABM,FRCP Autoimmune hepatobiliary diseases The liver is an important target for immunemediated injury. Three disease phenotypes are recognized:
More informationRadiology of hepatobiliary diseases
GI cycle - Lecture 14 436 Teams Radiology of hepatobiliary diseases Objectives 1. To Interpret plan x-ray radiograph of abdomen with common pathologies. 2. To know the common pathologies presentation.
More informationBronchobiliary fistula treated with histoacryl embolization under bronchoscopic guidance: A case report
Respiratory Medicine CME (2008) 1, 164 168 respiratory MEDICINE CME CASE REPORT Bronchobiliary fistula treated with histoacryl embolization under bronchoscopic guidance: A case report Jung Hyun Kim a,
More informationOverview of PSC Jayant A. Talwalkar, MD, MPH Associate Professor of Medicine Mayo Clinic Rochester, MN
Overview of PSC Jayant A. Talwalkar, MD, MPH Associate Professor of Medicine Mayo Clinic Rochester, MN 2012 Annual Conference PSC Partners Seeking a Cure May 5, 2012 Primary Sclerosing Cholangitis Multifocal
More informationGum O Jung and Dong Eun Park. Department of Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
Korean J Hepatobiliary Pancreat Surg 2012;16:110-114 Case Report Successful percutaneous management of bronchobiliary fistula after radiofrequency ablation of metastatic cholangiocarcinoma in a patient
More informationPowerPoint Made Easy(er)
PowerPoint Made Easy(er) Teachers of Tomorrow November 2017 The Problem Objectives The participant will be able to: 1. Select appropriate structural features in PowerPoint to enhance content delivery &
More informationCholangiocarcinoma: appearances and mimics
Cholangiocarcinoma: appearances and mimics Poster No.: C-1572 Congress: ECR 2011 Type: Educational Exhibit Authors: C. Cardenas Valencia, J. Fernandez Jara, J. Cubero Carralero, B. Corral Ramos, P. Perez
More informationEndoscopic treatment of primary sclerosing cholangitis: Is there something new?
Endoscopic treatment of primary sclerosing cholangitis: Is there something new? Arnaud Lemmers, MD, PhD Gastroenterology Department, Erasme Hospital, ULB, Brussels BASL December 1st 2017 AGENDA Introduction
More informationCASE 01 LA Path Slide Seminar 13 March, 08. Deepti Dhall, MD Department of Pathology and Laboratory Medicine Cedars-Sinai Medical Center
CASE 01 LA Path Slide Seminar 13 March, 08 Deepti Dhall, MD Department of Pathology and Laboratory Medicine Cedars-Sinai Medical Center Clinical History 60 year old male presented with obstructive jaundice
More informationRokitansky-Aschoff sinuses are epithelial invaginations in the gallbladder wall that from as a result of increased gallbladder pressures.
Anatomy The complexity of the biliary tree can be broken down into much simpler segments. The intrahepatic ducts converge to form the right and left hepatic ducts which exit the liver and join to become
More informationNavigating the Biliary Tract with CT & MR: An Imaging Approach to Bile Duct Obstruction
Navigating the Biliary Tract with CT & MR: An Imaging Approach to Bile Duct Obstruction Ann S. Fulcher, MD Medical College of Virginia Virginia Commonwealth University Richmond, Virginia Objectives To
More informationACUTE CHOLANGITIS AS a result of an occluded
Digestive Endoscopy 2017; 29 (Suppl. 2): 88 93 doi: 10.1111/den.12836 Current status of biliary drainage strategy for acute cholangitis Endoscopic treatment for acute cholangitis with common bile duct
More informationCLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION
Donald L. Renfrew, MD Radiology Associates of the Fox Valley, 333 N. Commercial Street, Suite 100, Neenah, WI 54956 8/27/2011 Radiology Quiz of the Week # 35 Page 1 CLINICAL PRESENTATION AND RADIOLOGY
More informationCase Scenario 1. Discharge Summary
Case Scenario 1 Discharge Summary A 69-year-old woman was on vacation and noted that she was becoming jaundiced. Two months prior to leaving on that trip, she had had a workup that included an abdominal
More informationCystic liver lesion and eosinophilia
November, 2005 Cystic liver lesion and eosinophilia Jakob Begun, Harvard medical School Year III Patient Presentation 55 year old Cape Verde female presented to her PCP with 6 month history of variable
More informationIntraductal papillary mucinous neoplasm of the bile ducts: a rare form of premalignant lesion of invasive cholangiocarcinoma
Intraductal papillary mucinous neoplasm of the bile ducts: a rare form of premalignant lesion of invasive cholangiocarcinoma Authors: R. Revert Espí, Y. Fernandez Nuñez, I. Carbonell, D. P. Gómez valencia,
More informationBILIARY TRACT & PANCREAS, PART II
CME Pretest BILIARY TRACT & PANCREAS, PART II VOLUME 41 1 2015 A pretest is mandatory to earn CME credit on the posttest. The pretest should be completed BEFORE reading the overview. Both tests must be
More informationDiagnosis and Management of Primary Sclerosing Cholangitis:
Diagnosis and Management of Primary Sclerosing Cholangitis: The Role of the Endoscopist Adam Slivka MD-PhD Associate Chief of the Division Gastroenterology Hepatology and Nutrition University of Pittsburgh
More informationThe Endoscopic Management of PSC
The Endoscopic Management of PSC Raj J. Shah, M.D. Associate Professor of Medicine Director, Pancreaticobiliary Endoscopy Services University of Colorado at Denver and the Health Sciences Center Why did
More informationACG Clinical Guideline: Primary Sclerosing Cholangitis
ACG Clinical Guideline: Primary Sclerosing Cholangitis Keith D. Lindor, MD, FACG 1, Kris V. Kowdley, MD, FACG 2, and M. Edwyn Harrison, MD 3 1 College of Health Solutions, Arizona State University, Phoenix,
More informationState of the Art Imaging for Hepatic Malignancy: My Assignment
State of the Art Imaging for Hepatic Malignancy: My Assignment CT vs MR vs MRCP Which one to choose for HCC vs Cholangiocarcinoma What special protocols to use for liver tumors Role of PET and Duplex US
More informationHepatobiliary Ultrasound Rimon Bengiamin, MD, RDMS Assistant Clinical Professor Director of Emergency Ultrasound UCSF Fresno. Objectives. Why?
Hepatobiliary Ultrasound Rimon Bengiamin, MD, RDMS Assistant Clinical Professor Director of Emergency Ultrasound UCSF Fresno Objectives Discuss the goals of point-of-care biliary ultrasound Review the
More informationLiver and Pancreatic Case discussion
The Royal Marsden Liver and Pancreatic Case discussion Dr Ian Chau Consultant Medical Oncologist The Royal Marsden 77 year old gentleman with 2 months history of vague abdominal ache and clinically finding
More informationCongenital dilatation of the common bile duct and pancreaticobiliary maljunction clinical implications
Langenbecks Arch Surg (2009) 394:209 213 DOI 10.1007/s00423-008-0330-6 CURRENT CONCEPT IN CLINICAL SURGERY Congenital dilatation of the common bile duct and pancreaticobiliary maljunction clinical implications
More informationResident Teaching Conference 10/16/09 Rondi Kauffmann Resident presenter William Nealon Faculty presenter
Resident Teaching Conference 10/16/09 Rondi Kauffmann Resident presenter William Nealon Faculty presenter KC 59 year old male Referred to Surgery clinic for incidentally discovered 5cm x 3cm pancreatic
More informationTata Memorial Centre s opinion is summarized as follows: 1. Given the type 1 stricture (as mentioned in the structured summary), assessment
March 5 th 2016 Dear Ms. Malti Sinha, Thank you for reaching out to Tata Memorial Centre for an expert opinion in regard to assessing your treatment options. Navya Network is pleased to offer this online
More informationThe Bile Duct (and Pancreas) and the Physician
The Bile Duct (and Pancreas) and the Physician Javaid Iqbal Consultant in Gastroenterology and Pancreato-biliary Medicine University Hospital South Manchester Not so common?! Two weeks 38 ERCP s 20 15
More informationThe authors have declared no conflicts of interest.
Diagnostic Accuracy of Magnetic Resonance Cholangiopancreatography Versus Endoscopic Retrograde Cholangiopancreatography Findings in the Postorthotopic Liver Transplant Population Authors: *Ashok Shiani,
More informationIdiopathic adulthood ductopenia manifesting as jaundice in a young male
Idiopathic adulthood ductopenia manifesting as jaundice in a young male Deepak Jain*,1, H. K. Aggarwal 1, Avinash Rao 1, Shaveta Dahiya 1, Promil Jain 2 1 Department of Medicine, Pt. B.D. Sharma University
More informationPANCREATIC PSEUDOCYST DRAINAGE: ENDOSCOPIC APPROACHES & THE NURSING ROLE. PRESENTED BY: Susan DePasquale, CGRN, MSN
PANCREATIC PSEUDOCYST DRAINAGE: ENDOSCOPIC APPROACHES & THE NURSING ROLE PRESENTED BY: Susan DePasquale, CGRN, MSN Pancreatic Fluid Collection (PFC) A result of pancreatic duct (PD) and side branch disruption,
More informationVascular complications in percutaneous biliary interventions: A series of 111 procedures
Vascular complications in percutaneous biliary interventions: A series of 111 procedures Poster No.: C-0744 Congress: ECR 2013 Type: Educational Exhibit Authors: A. BHARADWAZ; AARHUS, Re/DK Keywords: Obstruction
More informationBiliary Tree Ultrasound - In a nutshell. Pamela Parker Lead Sonographer
Biliary Tree Ultrasound - In a nutshell Pamela Parker Lead Sonographer Aims Review what we know about the biliary system Common pathologies Pitfalls Reporting tips The Nutshell Background Biliary examinations
More informationLIVER SURGERY 2. Case 1. Med 5 Refresher Course (Surgery) 2013/14. Dr Sunny Cheung
LIVER SURGERY 2 Med 5 Refresher Course (Surgery) 2013/14 24 Jun 2013 Dr Sunny Cheung Case 1 50/M Sudden onset of epigastric pain Abdominal distension Confused HR 120 BP 80/50 Haemocue = 8 What should you
More informationCME Article Clinics in diagnostic imaging (115) Wai C T, Seto K Y, Sutedja D S
Medical Education Singapore Med.1 2007, 48 (4) : 361 CME Article Clinics in diagnostic imaging (115) Wai C T, Seto K Y, Sutedja D S fit. B CD - -0 o -5 r t -10 Fig. I US images of the upper right abdomen
More informationEn-liang Li 1,2, Rong-fa Yuan 1, Wen-jun Liao 1, Qian Feng 1, Jun Lei 1, Xiang-bao Yin 1, Lin-quan Wu 1* and Jiang-hua Shao 1
Li et al. BMC Surgery (2019) 19:16 https://doi.org/10.1186/s12893-019-0480-1 RESEARCH ARTICLE Open Access Intrahepatic bile exploration lithotomy is a useful adjunctive hepatectomy method for bilateral
More informationIntrahepatic Cholangiocarcinoma Associated with Intrahepatic Duct Stones
Original Article Intrahepatic Cholangiocarcinoma Associated with Intrahepatic Duct Stones Hoon Hur, Il-Young Park, Gi-Young Sung, Do-Sang Lee, Wook Kim and Jong-Man Won, Department of Surgery, Holy Family
More informationClinical Study Recurrent Pyogenic Cholangitis: Disease Characteristics and Patterns of Recurrence
ISRN Surgery Volume 2013, Article ID 536081, 9 pages http://dx.doi.org/10.1155/2013/536081 Clinical Study Recurrent Pyogenic Cholangitis: Disease Characteristics and Patterns of Recurrence Ye Xin Koh,
More informationIT 의료융합 1 차임상세미나 복부질환초음파 이재영
IT 의료융합 1 차임상세미나 2013-4-3 복부질환초음파 이재영 나는오늘누구를위하여 종을울리나? 전통적의료 의사 공학설계자 의사 최첨단진단장비들 USG, CT, MRI 환자 환자 현대의료 사용자중심의사고 US in the Abdomen Detection DDx Look Behavior Response by external stimuli Guiding Tool
More informationBackground. RUQ Ultrasound Normal, Recommend Clinical Correlation. Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial
RUQ Ultrasound Normal, Recommend Clinical Correlation Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial Background Incidence of pediatric gallbladder disease continues to rise U.S. Pediatric
More informationAfternoon Session Cases
Afternoon Session Cases Case 1 19 year old woman Presented with abdominal pain to community hospital Mild incr WBC a14, 000, Hg normal, lipase 100 (normal to 75) US 5.2 x 3.7 x 4 cm mass in porta hepatis
More informationCHIEF COMPLAINT & HPI
THE GREAT HOUDINI Resident: Marc Lim, MD Attending: Shekher Maddineni, MD Program/Department: Westchester Medical Center/New York Medical College/Department of Radiology CHIEF COMPLAINT & HPI Chief Complaint
More informationCase Reports. Intraductal Papillary Cholangiocarcinoma: Case Report and Review of the Literature INTRODUCTION CASE REPORT
Case Reports Kongkam K, Rerknimitr R 45 Case Report and Review of the Literature Pradermchai Kongkam, M.D. Rungsun Rerknimitr, M.D. ABSTRACT A case of papillary cholangiocarcinoma is presented. A 64-year-old
More informationKNIFED IN THE ABDOMEN
Originally Posted: November 01, 2014 KNIFED IN THE ABDOMEN Resident(s): Andrew Duarte, MD Attending(s): Ryan Scott, MD & David Kay, MD Program/Dept(s): St. Joseph s Hospital and Medical Center, Phoenix,
More informationBiliary Papillomatosis: case report
Chin J Radiol 2003; 28: 407-412 407 Biliary Papillomatosis: case report CHUN-LIN HUANG WEN-PIN CHEN YU-BUN NG JOSEPH HANG LEUNG Department of Medical Imaging, Chiayi Christian Hospital Biliary papillomatosis
More information