Computed tomography intravenous cholangiography

Indications for direct visualization of the bile ducts include bile duct dilatation demonstrated by ultrasound or CT scanning, where the cause of the bile duct dilatation is uncertain or where the anatomy of bile duct obstruction needs further clarification. Another indication is right upper quadrant pain, particularly in a post-cholecystectomy patient, where choledocholithiasis is suspected. A possible new indication is pre-operative evaluation prior to laparoscopic cholecystectomy. The bile ducts are usually studied by endoscopic retrograde cholangiopancreatography (ERCP), or, less commonly, trans-hepatic cholangiography. The old technique of intravenous cholangiography has fallen into disrepute because of inconsistent bile-duct opacification. The advent of spiral CT scanning has renewed interest in intravenous cholangiography. The CT technique is very sensitive to the contrast agent in the bile ducts, and angiographic and three-dimensional reconstructions of the biliary tree can readily be obtained using the CT intravenous cholangiogram technique (CT IVC). Seven patients have been studied using this CT IVC technique, between February 1995 and June 1996, and are the subject of the present report. Eight further studies have since been performed. The results suggest that CT IVC could replace ERCP as the primary means of direct cholangiography, where pancreatic duct visualization is not required.     

Usefulness of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of hepatic,gallbladder and biliary tract Lesions

Endoscopic ultrasound(EUS)-guided fine needle aspira-tion(FNA) of the liver is a safe procedure in the diag-nosis and staging of hepatobiliary malignancies with a minimal major complication rate. EUS-FNA is useful for liver lesions poorly accessible to other imaging modali-ties of the liver. EUS-guided FNA of biliary neoplasia and malignant biliary stricture is superior to the con-ventional endoscopic brushing and biopsy.     

Clinical Efficacy of Endoscopic Pancreatic Drainage for Pain Relief with Malignant Pancreatic Duct Obstruction

Objective: This study was conducted to investigate the efficacy of pancreatic drainage for pain relief in advanced pancreatic cancer. Method: Seventy-one patients with pancreatic carcinoma were divided into two groups: dilated and non-dilated pancreatic ducts. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic biliary stenting and pancreatic stenting. Visual Analog Scale (VAS) scores, pain remission rates and survival time were evaluated during follow-up. Results: The post-ERCP VAS score of the dilated group was lower than that of the non-dilated group at 1 and 3 months post-ERCP. There was no difference at 6 months. The pain remission rate in the dilated duct group was significantly higher than that in non-dilated duct groupin 1 and 3 months post-ERCP. The median survival times were 8.17 and 8.22 months respectively. Conclusion: Endoscopic pancreatic drainage can relieve pain of advanced pancreatic cancer accompanied by safe dilation of the pancreatic duct.     

影像学诊断恶性胆道梗阻和术前评估肿瘤切除的准确性

目的 探讨影像学诊断恶性胆道梗阻的价值和术前评估肿瘤切除的准确性。方法 对61例经病理或临床证实的恶性胆道梗阻病人，进行影像学检查资料总结。结果 对恶性胆道梗阻病人行B超、CT、ERCP或PTC、MRCP检查，术前临床诊断准确率分别为80.3%、85.2%、90.6%、90.0%、92.3%，术前评估肿瘤切除准确性:85%、78.4%、66.7%、73.1%、93.3%。结论 恶性胆道梗阻在定性诊断上MRCP、ERCP、PTC诊断率高于B超、CT，在手术可切除性评估方面MRCP、B超高于CT、ERCP、PTC，但均无统计学意义。     

Ultrasonic Demonstration of Anicteric Biliary Obstruction

25 non jaundiced patients with dilatation of the biliary tree are presented. In 22 of these cases the cause of obstruction was shown either by ultrasound alone, on radionuclide (RN) study or at endoscopic retrograde cholangiography (ERCP) and was subsequently proven at surgery. In 2 cases ultrasound showed dilatation of the common duct, which was proved to be non-obstructive dilatation on ERCP. One patient had multiple benign hepatic cysts with intrahepatic biliary dilatation and was not subjected to surgery. Twenty out of 23 patients with obstructive dilatation showed a variable rise in serum alkaline phosphatase. Bile duct size did not show any correlation with serum alkaline phosphatase levels. It is stressed that ultrasound is a more sensitive indicator of obstructive biliary disease than clinical and biochemical parameters.     

恶性梗阻性黄疸的内镜姑息治疗(附929例报道)

Objective:To review the experience with endoscopic palliative treatment for malignant obstructive jaundice (MOJ) in 929 patients. Methods:929 patients (598 males and 331 females) underwent 1215 endoscopic palliative drainages for MOJ in our hospital. Tumor obstruetion oeeurred in the distal common bile duet(CBD)(263 patients), the middle CBD (43),and the hilum(909).The mean bilirubin level was 284.3 μmol/L(range 26-810). Of the 1215 drainages, 599 were performed by stenting with plastic endoprosthesis, 385 by naso-biliary eatheterization, 167 by expandable metal stents,39 by combined drainage method,19 by tumor sphincterotomy and 6 by endoseopie fistulostomy. Results:The successful rate of endoscopic procedure was 94.3%. The jaundice symptom was improved in 81.8% of the patients with a significant reduetion of serum bilirubin in 64.7%. The complication after treatment occurred in 23 eases (2.6%), including eholangitis(23 eases), panereatitis (8 eases), and bleeding (one ease), and 3 eases were dead (0.2%).The median survival time of all patients was 14 months and life time analysis showed a life expectancy of 75.9%, 44.0% and 25.2% at 1, 2 and 3 years respectively. Conclusion:In the patients with MOJ seeondary to panereatobiliary malignancy, sueeessful endoscopic drainage provides adequate relief of biliary obstruetion and is associated with low morbidity and mortality. Enduseopie interventional treatment may be considered as an alternative of palliative biliary operation for the late stage of pancreatic and biliary malignaneies.     

Magnetic Resonance in Obstructive Jaundice

Twelve cases of obstructive jaundice in whom ultrasound failed to demonstrate the site and/or the cause of obstruction of the biliary tract were examined with magnetic resonance imaging (MRI), correctly diagnosing the site and cause of obstruction in 10 of 12 surgically proven cases. In one case of cholangiocarcinoma, the site of obstruction was well shown on MR but a definite cause could not be ascertained. In another patient who developed intermittent jaundice following surgery for choledochal cyst, MR demonstrated a solitary stone in the common hepatic duct. Surgical confirmation could not be achieved as the patient was lost to follow up. There were 6 cases of choledocholithiasis, 3 cases of gall bladder carcinoma and one case each of pancreatic adenocarcinoma and cholangiocarcinoma. It is believed that MRI will provide obstructive jaundice and will be able to minimize the use of percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP) in view of its ability to perform multiplanar imaging in multiple sequences.     

Imaging of the normal and abnormal pancreatico-biliary system with single-shot MR cholangiopancreatography: A pictorial review

Magnetic resonance cholangiopancreatography (MRCP) is a rapidly evolving non-invasive imaging modality that produces images of the pancreatic duct and biliary tree without the need for intravenous or oral contrast. The images are equivalent to those from endoscopic retrograde cholangiopancreatography (ERCP), but the non-invasive acquisition avoids the morbidity and mortality associated with diagnostic ERCP. Magnetic resonance cholangiopancreatography is indicated in patients who require only a diagnostic ERCP, who fail an ERCP or who are unable to undergo ERCP due to altered post-surgical anatomy. Other evolving indications include triaging of patients with obstructive jaundice into percutaneous or endoscopic management drainage pathways depending on the site, length and nature of the duct obstruction, thereby potentially decreasing the number of failed or unsuccessful ERCP. Pre-operative identification of anomalous biliary anatomy and choledocholithiasis prior to laparoscopic cholecystectomy promise to modify the pre-operative and operative management of the patient in order to minimize the risk of duct injury and unnecessary intra-operative dissection and cholangiography. The advantages of the technique include its non-invasiveness, the absence of contrast administration, its relative operator independence and the ability to evaluate both sides of an obstructed duct, thereby accurately evaluating stricture morphology and length. The disadvantages of MRCP compared to ERCP include its lack of an immediate therapeutic solution to duct obstruction, procedural cost, unit availability and the inability to evaluate patients with pacemakers or ferromagnetic implants.     

Palliative percutaneous drainage in malignant biliary obstruction. Part 1: indications and preprocedure evaluation

A diagnosis of liver metastasis, periportal adenopathy, or hepatobiliary cancer often is accompanied by findings of biliary obstruction. Malignant biliary obstruction frequently is associated with pruritus, anorexia, cholangitis, or hyperbilirubinemia, which that precludes treatment with chemotherapeutic agents that are excreted or metabolized hepatically. In patients with low biliary obstruction, endoscopic stent placement may accomplish drainage of the entire biliary tree without the need for an external device. Patients with high bile duct obstruction, on the other hand, may need a percutaneous approach to drain the target ducts and avoid draining an atrophic segment or lobe.This first of a series of two articles concerning palliative percutaneous biliary intervention will review the indications for biliary drainage and the preprocedure evaluation of this complicated patient population.     

Palliative Therapie des fortgeschrittenen Pankreaskarzinoms

In spite of advances in the management of other malignancies, the prognosis of patients with advanced pancreatic cancer remains poor. Palliative therapy is an essential element of the treatment strategy. In this review we discuss important areas of the palliative therapy of advanced pancreatic cancer. We focus on complications of pancreatic cancer, such as stenosis of the common bile duct, duodenal obstruction and thrombosis as well as on supportive therapy. The endoscopic implantation of self-expanding metal stents is a safe procedure with a high success rate to obtain adequate biliary drainage. In cases of malignant duodenal obstruction palliation is also mainly achieved by endoscopic stenting. A main area of supportive care is an appropriate pain treatment, following the WHO scheme for pain therapy. Weight loss in patients with pancreatic cancer is often due to pancreatic exocrine insufficiency, which is treated by supplementation of pancreatic enzymes.     

Gallbladder cystadenoma and common bile duct obstruction

Cystadenomas are usually found in the extra-hepatic bile ducts in conjunction with multilocular cysts in the liver. Cystadenoma of the gallbladder itself is a rare finding, cited only once in the literature as the cause of extrinsic obstruction of the common bile duct (5). In this report, we describe the endoscopic retrograde cholangiopancreaticographic (ERCP) detection of intrinsic obstruction of the cystic duct and common bile duct by such a tumor in a 47-yr-old woman.     

A study of 272 cases of endoscopic dacryocystorhinostomy

272 Patients with obstruction in nasolacrimal duct were treated by endoscopic nacryocystorhinostomy (DCR). The results were compared with that of external DCR and Endoscopic DCR without stent. In our study Endoscopic DCR with stening had better results. Endoscopic DCR with stenting has several advantages over the more conventional external approach and Endoscopic DCR without stenting. Results at 4 years of follow up have been good that is 98.6% patients were relieved of symptoms completely.     

Percutaneous fine-needle aspiration cytologic study of main pancreatic duct stenosis under pancreatographic guidance

When pancreatography shows a stenosis of the main pancreatic duct in patients with normal or inconclusive ultrasound and computed tomography, the exact nature of such stenosis is sometimes difficult to precise before surgical exploration. In such cases, the authors systematically performed a percutaneous fine-needle aspiration cytologic study of the stenosis under pancreatographic guidance. Fifteen patients were referred because of suspected pancreatic malignancy. The tumor markers, carcinoembryonic antigen (CEA) and CA 19-9 were normal in 11 patients and elevated in one patient, whereas only CA 19-9 was elevated in three others. In 14 cases, both the ultrasound and computed tomography did not show any obvious pancreatic mass. The pancreatography was done through endoscopic retrograde cholangiopancreatography (ERCP) (12 patients) or percutaneously in case of failure at ERCP3 and showed a main pancreatic duct stenosis that underwent aspiration by percutaneous fine needle precisely positioned using biplane fluoroscopy. The aspirated material was then smeared on glass slides, air-dried, and stained by Giemsa. In nine of the 15 patients, cytologic study revealed adenocarcinoma. This was confirmed by surgery in five and by progressive deterioration followed by death in four. In six patients, cytologic study gave a nonmalignant result. Chronic pancreatitis was found in five of them, confirmed at surgery in three and based on uneventful follow-up of at least 12 months in two others. In one case, a pancreatic adenocarcinoma not detected by cytologic study was found at surgery. Thus, the sensitivity and specificity of this diagnostic approach were 90% and 100%, respectively. No serious complication was noticed. The authors conclude that when ultrasound and computed tomography are inconclusive, percutaneous fine-needle aspiration cytologic study of main pancreatic duct stenosis under pancreatographic guidance is a safe, simple, and helpful procedure in the investigation of patients with suspected pancreatic malignancy.     

Magnetic resonance cholangiopancreatography

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging method for examining the biliary and pancreatic ducts. The technique uses heavily T2-weighted imaging, which produces high signal from bile and other static fluids by virtue of their long T2 time, while suppressing background signal. Fast scanning techniques, particularly half-Fourier fast spin-echo techniques, are continuing to improve image resolution and allow scans within short breath-holds, reducing the effects of respiratory movement. The MRCP method has reached a level of resolution and reliability where it may well largely replace diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in the near future. A review of MRCP techniques and imaging findings is presented with emphasis on half-Fourier imaging, with reference to potential clinical indications and limitations. Use of MRCP shows a high sensitivity and specificity for detection of biliary dilatation, calculi, strictures and anatomical variants. Experience with MR imaging of the pancreatic duct is less extensively described in the literature, but pancreatic duct dilatation, calculi and anatomy can now be reliably detected. However, as experience with MRCP increases, some sources of errors and limitations are becoming apparent, with image artefacts, and gas, blood or sludge within ducts potentially mimicking stones or strictures.     

肝外胆管癌的介入治疗现状与展望

肝外胆管癌是指源于肝外胆管包括肝门区至胆总管下端胆管的恶性肿瘤.在美国癌症联合会(American Joint Committee on Cancer,AJCC)第8版指南中,肝外胆管癌被分类分为肝门胆管癌和远端胆管癌两部分.近年来,肝外胆管癌的发病率逐渐升高,且预后较差,手术切除在治疗中的局限性逐渐体现.在胆管癌的诊...     

Pancreatic heterotopia and other uncommon causes of non-malignant biliary obstruction

The vast majority of patients developing obstructive jaundice will have an underlying malignancy. When the etiology of the obstruction cannot be defined prior to operative intervention, identification of a non-malignant process will occur only subsequent to a major operation. The clinical course of a patient with complete distal common bile duct obstruction as the result of pancreatic heterotopia is discussed. This uncommon diagnosis prompted a review of the literature on this subject enabling this detailed discussion inclusive of the embryology, prevalence and clinical presentations of this entity. Our review further identified a varied group of other non-malignant causes of biliary obstruction that may be mistakenly interpreted to represent biliary or pancreatic malignancy.     

A case report of cholangiectasis with cholangiocarcinoma

This is a case report of cholangiectasis with cholangiocarcinoma in a 37-year-old female. Both computed tomography (CT) and endoscopic retrograde cholangio-pancreatography (ERCP) demonstrated gallstone, and intrahepatic bile duct dilatation with the stone. The diagnosis was intrahepatic cholangiectasis without common bile duct-dilatation. Hepatectomy of segment 3 with resection of the extrahepatic bile duct and reconstruction of the biliary tract was performed. Upon pathological examination, an early stage of cholangiocarcinoma was pointed out within the small range of common bile duct without dilatation or stone. Cholangiocarcinoma with cholangiectasis has been reported to be induced by counter flow of pancreas and intestinal juice because of the pancreaticobiliary maljunction. So we usually choose a diversion operation as our tactics to get rid of the counter flow of those digestive juices. Despite the above-mentioned tendency, this is a very rare case of carcinogenesis in common bile duct without dilatation.     

ERCP对肝外胆管癌的诊断价值

目的 对经手术证实的33例肝外胆管癌的ERCP资料进行回顾性分析。方法 33例肝外胆管癌患者均行ERCP检查,并与B超和CT检查结果进行对照。结果 33例肝外胆管癌病变位于上段者20例(60.6％),中段者6例(18.2％),下段者7例(21.2％)。ERCP成功32例(97.0％),定性准确率为96.0％,B超定性准确率为70.8％,CT定性准确率为78.8％。结论ERCP在早期诊断肝外胆管癌方面明显优于B超和CT检查,并能清晰地显示胆管系统的全貌,对治疗和手术的选择有重要价值。     

内镜下球囊扩张术在胆管癌细胞刷检中的应用价值

目的:探索内镜下球囊扩张术联合胆道细胞刷检应用于胆管癌的诊断价值.方法:单中心前瞻性研究2018年1月至2020年1月华中科技大学同济医学院附属武汉中心医院经影像学(CT或MRI)提示胆管恶性狭窄可能或原因不明胆管狭窄并同意逆行胰胆管造影(endoscopic retrograde cholangiopancreato...     

Endoscopic treatment options for cholangiocarcinomas

Cholangiocellular carcinoma (CCC) is a very aggressive tumor, which remains highly resistant to current chemoradiation therapies. Death is usually caused by the tumor burden. However, biliary obstruction, which leads to cholangitis and liver failure, is also a cause of death. Therefore, relief of biliary obstruction is one of the key palliative treatment options for patients with hilar or distal CCC. Radiologic or endoscopic insertions of stents (plastic or self-expanding metal) are definite biliary drainage options. Whereas stents alone can help achieve relief of bile duct obstruction, endoscopic ablative interventions with photodynamic therapy or radiofrequency ablation are also useful in destroying intraluminal tumor. Destroying the tumor leads to an increase in the luminal diameter of the obstructed bile duct, allowing for placement of more or larger diameter stents, and thus improving bile flow. Besides decreasing morbidity associated with obstruction, ablative therapies such as photodynamic therapy have also been associated with improved survival in a sub-group of patients with CCC and should therefore be incorporated into the treatment algorithm of any center treating patients with CCC.