Portal vein embolization in the treatment of portal vein bleeding after percutaneous transhepatic biliary drainage: A case report and literature review

Percutaneous transhepatic biliary drainage (PTBD) is an effective treatment for benign and malignant obstructive jaundice. Major bleeding complications occur in approximately 2–3% of patients after PTBD, which can result in death. A case involving a 63-year-old male with malignant obstructive jaundice, who experienced severe bleeding after PTBD, is reported. Emergency digital subtraction angiography, celiac trunk artery and superior mesenteric artery angiography were performed; however, no signs of arterial bleeding were found. To identify etiology, portal venography was performed under ultrasound guidance and portal vein bleeding was diagnosed. Ultimately, selective portal vein embolization successfully stopped the bleeding.     

Laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis in a patient with a left ventricle assist device: A case report and brief review of the literature (with video)

For acute cholecystitis in patients with left ventricular assist devices, the use of percutaneous transhepatic gallbladder drainage to calm inflammation before planned laparoscopic cholecystectomy may be helpful in safely adjusting anticoagulation and in performing safe laparoscopic cholecystectomy, as demonstrated in this case.     

Resolving hyperlipidemia after liver transplantation in a patient with primary sclerosing cholangitis

A 64-year-old man with primary sclerosing cholangitis (PSC) and resultant liver failure presented to our hospital with severe dyslipidemia (total cholesterol, 525 mg/dL; low-density lipoprotein (LDL) cholesterol, 489 mg/dL; high-density lipoprotein (HDL) cholesterol, 13 mg/dL; triglycerides, 114 mg/d) and coronary artery disease. The abnormal lipid profile of patients with cholestatic liver disease, such as PSC, includes an abnormal atherogenic LDL called lipoproteinX. The patient's dyslipidemia persisted despite treatment with a statin. Lipids normalized only after liver transplantation (total cholesterol, 135 mg/dL; LDL cholesterol, 60 mg/dL; high-density lipoprotein cholesterol, 48 mg/dL; triglycerides, 130 mg/dL). To the best of our knowledge, the dramatic improvement in the lipid profile after liver transplantation represents the first such published report for PSC. The recognition of dyslipidemia and atherosclerosis in those with cholestatic liver disease and the normalization of lipid profile after liver transplantation warrant further study. We present a review of dyslipidemia in cholestatic liver disease, its relationship to atherosclerosis, and its treatment.     

Portal hypertension in a patient with biliary hamartomas: A case report

BACKGROUND Biliary hamartomas(BH)are a rare benign disease caused by malformation of the intrahepatic bile ducts.BH are occasionally diagnosed,but often lack obvious clinical symptoms.They are usually diagnosed by biopsy and imaging tests in clinical practice.Few studies have reported the association of BH with portal hypertension.CASE SUMMARY A 40-year-old man was repeatedly admitted to our hospital due to hematochezia.The source of bleeding was considered to be gastroesophageal varices and portal hypertensive gastropathy by endoscopy.He had no history of hepatitis virus infection,alcohol abuse,drug-induced liver injury,or autoimmune liver disease.He underwent magnetic resonance imaging,which showed rounded,irregular,low-signal-T1 and high-signal-T2 lesions diffusely distributed on the liver,that were not communicated with the biliary system on magnetic resonance cholangiopancreatography.According to the imaging examination,the patient was considered to have a diagnosis of BH with portal hypertension.CONCLUSION Based on the present case report,BH may be a potential etiology of portal hypertension.     

Immunosuppressant treatment for IgG4-related sclerosing cholangitis: A case report

BACKGROUNDImmunoglobulin G4-related disease (IgG4-RD) is a multi-system fibroin-flammatory disorder that can involve any organ, including the salivary glands, pancreas, and biliary tree. Treatment of immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is similar to that for IgG4-RD, but progression is irreversible in some cases. We present a case of IgG4-SC in which an immuno-suppressant induced marked clinical and radiologic improvement.CASE SUMMARYA 63-year-old male presented with a prominent itching sensation and wholebody jaundice. He showed obstructive-pattern jaundice, an elevated IgG4 level, and infiltration of a large number of IgG4-positive cells in the ampulla of Vater. The imaging findings of intrahepatic duct (IHD) and common bile duct dilation, an elevated serum IgG4 level, and characteristic histological findings led to diagnosis of IgG4-SC that compatible with the 2019 ACR/EULAR classification criteria. We planned to treat the patient with high-dose glucocorticoid (GC), followed by cyclophosphamide pulse therapy. After treatment with high-dose GC and an immunosuppressant, imaging studies showed that IHD dilatation had completely resolved.CONCLUSIONPrompt diagnosis and appropriate treatment of IgG4-SC are important. Because there is a risk of relapse of IgG4-SC, the GC dose should be gradually reduced, and a maintenance immunosuppressant should be given.     

Ultrasound and fluoroscopy guided percutaneous transhepatic biliary drainage in patients with nondilated bile ducts

Background  The purpose of this study is to demonstrate the feasibility, safety, and success of percutaneous transhepatic biliary drainage (PTBD) using a combination of ultrasound and fluoroscopy guidance in patients with nondilated bile ducts. Methods  Between January 2005 and July 2007, 50 patients with nondilated bile ducts underwent ultrasound-and-fluoroscopy guided PTBD. The underlying disease processes were divided into biliary obstruction (n = 38) and bile leakage (n = 12). We used ultrasound guidance when puncturing a bile duct and during cholangiography. We punctured along the course of the targeted bile duct or portal vein when the bile duct was not visualized, which we termed the “parallel technique.” This method made it possible for us to cannulate the peripheral bile duct successfully, even when its course was not visualized well by sonography. We then installed a drainage catheter under fluoroscopy guidance. The technical success and complications of the procedure were evaluated. Results  Neither significant complications nor technical failures were observed. There were only four minor complications: transient hemobilia (n = 3) and fever (n = 1). Conclusions  Ultrasound-and-fluoroscopy guided PTBD in patients with nondilated bile ducts is a safe, feasible, and efficient procedure for the palliation of biliary obstruction and leakage.     

内镜逆行胰胆管造影术与经皮肝穿刺胆道引流术治疗肝外胆管梗阻性黄疸的对比研究

目的探讨内镜逆行胰胆管造影术(ERCP)与经皮肝穿刺胆道引流术(PTCD)在治疗良、恶性肝外胆管梗阻性黄疸方面各自的优劣。方法回顾性分析2013年5月至2014年7月期间兰州大学第二医院普外四科收治的肝外胆管梗阻性黄疸患者并分别采用ERCP与PTCD治疗的临床资料,比较2种方法的手术成功率、5 d血清胆红素下降水平及术后常见并发症的发生率等。结果与PTCD相比,ERCP在治疗良性肝外胆管梗阻性黄疸时,术后5 d血清总胆红素水平下降速度较快[(94.9±11.58)μmol/L vs.(84.3±15.50)μmol/L,t=2.946,P=0.005],术后并发症发生率较低(3.3%vs.21.4%,χ2=4.469,P=0.035),但手术成功率(96.7%vs.92.9%,χ2=0.429,P=0.513)二者无统计学差异。在治疗恶性肝外胆管梗阻性黄疸时,两种方法术后常见并发症的发生率(9.5%vs.18.5%,χ2=0.767,P=0.381)虽无明显差异,但相比ERCP,在手术成功率(95.2%vs.70.4%,χ2=4.795,P=0.029)和术后5 d血清总胆红素水平下降速度[(206.3±13.26)μmol/L vs.(186.8±20.59)μmol/L,t=-2.516,P=0.015]方面PTCD组效果较为显著。结论对于良性肝外胆管梗阻性黄疸患者ERCP不仅具有创伤小、并发症少、起效快、疗效好的优点,而且可以从根本上解除梗阻;而对于恶性肝外胆管梗阻性黄疸,由于PTCD手术成功率高,可以有效缓解梗阻症状,快速降低血清胆红素水平,改善肝功能,提高患者生活质量,因此成为首选方法。     

Percutaneous transhepatic cholangiography and biliary drainage after liver transplantation: A five-year experience

Evaluation of the biliary tract by percutaneous transhepatic cholangiography (PTC) is often required in liver transplant patients with an abnormal postoperative course. Indications for PTC include failure of liver enzyme levels to return to normal postoperatively, an elevation of serum bilirubin or liver enzyme levels, suspected bile leak, biliary obstructive symptoms, cholangitis, and sepsis.Over a 5-year period 625 liver transplants in 477 patients were performed at the University Health Center of Pittsburgh. Fifty-three patients (56 transplants) underwent 70 PTCs. Complications diagnosed by PTC included biliary strictures, bile leaks, bilomas, liver abscesses, stones, and problems associated with internal biliary stents.Thirty-two percutaneous transhepatic biliary drainage procedures were performed. Ten transplantation patients underwent balloon dilatation of postoperative biliary strictures. Interventional radiologic techniques were important in treating other complications and avoiding additional surgery in many of these patients.     

Effect of ursodeoxycholate on the biliary excretion of cefotiam and sulbenicillin in patients with percutaneous transhepatic biliary drainage.

The effects of ursodeoxycholate administration on the biliary excretion of the antibiotics cefotiam and sulbenicillin were studied in five patients with stable hepatic function receiving percutaneous transhepatic biliary drainage for obstructive jaundice. Cefotiam (I g) and sulbenicillin (2 g) were administered intravenously before and after ursodeoxycholate administration, and the maximum concentrations of the antibiotics in the bile and total amounts excreted in the bile during the 4 h after administration were determined. After ursodeoxycholate administration, both the maximum concentration of cefotiam in the bile and the amount excreted increased significantly. Ursodeoxycholate also increased the peak concentration and total excretion of sulbenicillin. For both cefotiam and sulbenicillin, the amount of antibiotic excreted in the bile during the 4 h after administration showed a significant correlation with the amount of bile acids excreted in the bile. This strongly suggests a common mechanism for the biliary excretion of these antibiotics and bile acids. Ursodeoxycholate administration is a benign way to increase both the concentration and the total amount of antibiotic excreted in the bile. Therefore, it may be useful in the treatment of serious biliary tract infections, especially in patients receiving biliary drainage.     

Laparoscopic internal intestinal drainage of bile lakes in a patient with recurrence of jaundice after laparoscopic revision of Kasai portoenterostomy for biliary atresia: A case report

Bile lake, of the postoperative complications after Kasai portoenterostomy (PE) for biliary atresia, causes cholangitis that may induce progressive fibrosis of the liver. Standard treatment for bile lakes has not yet been established, but there are reports that surgical internal intestinal drainage for bile lakes effectively prevents cholangitis and maintains jaundice-free status. In this case, insertion of the percutaneous transhepatic biliary drainage into the bile lake allowed continuous drainage of large volumes of bile juice. However, reoperation following laparotomy increases the surgical risk of subsequent liver transplantation due to postoperative adhesion. Laparoscopic surgery was selected for the patient who was likely to require liver transplantation in the future. In this case, laparoscopic internal intestinal drainage of bile lakes was performed safely by a Cavitron ultrasonic surgical aspirator for the recurrence of jaundice after laparoscopic revision of PE. Cholangitis and jaundice were rapidly resolved after this surgical procedure.     

经皮肝穿刺胆管引流联合腹腔镜微创治疗急性梗阻性化脓性胆管炎(附12例报告)

目的探讨经皮肝穿刺胆管引流(PTCD)联合腹腔镜治疗急性梗阻性化脓性胆管炎(AOSC)的疗效。方法PTCD联合腹腔镜治疗AOSC共12例。结果11例抢救成功,1例死亡,抢救成功率91.7%。结论PTCD联合腹腔镜治疗AOSC具有安全有效、创伤小和愈合快等优点,是微创治疗的有效方法之一。     

1例贲门失弛缓症经口内镜下肌切开术后气体并发症患者的护理

总结1例贲门失弛缓症经口内镜下肌切开术后发生气体并发症患者的护理经验。护理要点:术中密切观察患者生命体征,术后对患者出现的气体相关并发症有针对性地进行抢救、治疗及恢复期护理和指导,术后耐心与患者及家属沟通、讲解,缓解患者不良情绪,给予患者及家属心理护理。患者术后第19 d康复出院,随访1年,状况良好。     

Isolated mass-forming IgG4-related sclerosing cholangitis masquerading as extrahepatic cholangiocarcinoma: A case report

BACKGROUNDIgG4-related sclerosing cholangitis (IgG4-RSC) is an uncommon benign disease, and its rarer, isolated and mass-forming subtype poses a significant challenge to differential diagnosis from cholangiocarcinoma of the extrahepatic bile duct. We herein report a case of isolated IgG4-RSC with an obstructing bile duct mass, for which extrahepatic bile duct resection was performed under the impression of proximal common bile duct (CBD) cancer.CASE SUMMARYA 79-year-old male was admitted for jaundice that had developed 1 mo prior. There was no family history for autoimmune diseases or biliary cancer. Computed tomography (CT) and magnetic resonance cholangiopancreaticography revealed a short segmental concentric wall thickening of the proximal CBD with diffuse dilatation of the bile duct to the periphery. The endoscopic biopsy specimen showed no malignant cells. Positron emission tomography-CT showed a focal hypermetabolic lesion (SUVmax 4.2) in and around the proximal CBD area. With the impression of proximal CBD cancer, we performed segmental resection of the extrahepatic bile duct. Histopathology demonstrated marked sclerosis with diffuse lymphoplasmacytic infiltration and some eosinophils. Immunohistochemical staining for IgG4 showed increased positivity in some areas (up to 30/high-power field) and IgG4+/IgG+ cell ratio as 30%-50%. Pathologists’ impression was IgG4-related sclerosing disease. Follow-up serum IgG4 levels were continuously elevated; however, no evidence of relapse or other organ involvement related to IgG4-RSC presented.CONCLUSIONIsolated and mass-forming IgG4-RSC displays striking similarity with cholangiocarcinoma. To avoid unnecessary major surgery, high index of suspicion is needed.     

胰腺癌胆管扩张经超声引导PTBD术(附23例报告)

目的探讨超声引导下PTBD治疗胰腺癌梗阻性黄疸的临床应用价值。方法 23例胰腺癌病人,在超声引导下经皮用 18G针刺入扩张胆管内、通过“J”导丝置入引流管。结果肝总管及左右肝管内置管22支,导管置入失败一支,PTBD成功率96％。讨论超声引导下PTBD定位准确,穿刺时间短,成功率高,是较为安全、有效、病人易接受的胆道减压引流方法。     

Primary breast cancer patient with poliomyelitis: A case report

BACKGROUNDPoliomyelitis is an acute infection caused by an enterovirus, which primarily infects the human gastrointestinal tract. In general, patients with polio have no association with the occurrence of cancer. The present case study presents a rare case of poliomyelitis combined with primary breast cancer.CASE SUMMARYA 61-year-old woman who was diagnosed with poliomyelitis at 5 years old and confirmed invasive breast cancer by core needle biopsy (CNB) after hospitalization. The patient received a modified radical mastectomy and four cycles of chemotherapy with the TC (docetaxel and cyclophosphamide) regimen. The patient was also prescribed endocrine therapy without radiotherapy after chemotherapy. The patient had no evidence of lymphedema in the right upper extremities and no evidence of either regression or distant metastasis at the 1-year follow-up.CONCLUSIONThe pectoral muscles of patients with polio are easily damaged in traumatic procedures, such as CNB, local anesthesia for tumor excision, and general anesthesia for surgery. A CNB, modified radical mastectomy, and four cycles of TC chemotherapy were successfully completed for the present case and the adverse reactions were found to be tolerable. This case may indicate the relationship between breast cancer and polio, and the examination and treatment methods used could be used as a guide for similar cases in the future.