Hepatocellular Carcinoma with Invasion of the Right Intrahepatic Bile Duct Observed by Peroral Cholangioscopy: a Case Report

A 48-year-old chronic alcoholic with previous hepatitis B virus infection presented with recurrent episodes of obstructive jaundice secondary to hepatocellular carcinoma. The obstructive nature of the jaundice was confirmed by the peroral cholangioscopic findings of a friable nodular mass partially obstructing the right hepatic duct, and by relief of obstructive signs and symptoms after endoscopic sphincterotomy freed the common bile duct of “dark greenish formed materials”.     

Transcatheter arterial embolization for bleeding from bile duct tumor thrombi of hepatocellular carcinoma

BACKGROUND/AIMS: Advanced hepatocellular carcinoma usually invades the portal vein, forming tumor thrombi. Invasion of the bile duct, i.e., intrabile tumor growth or bile duct tumor thrombi is rare. Patients with bile duct tumor thrombi present with obstructive jaundice, abdominal pain or hemobilia. Hemobilia due to bile duct tumor thrombi is sometimes massive and fatal. The purpose of our study was to evaluate the effectiveness of transcatheter arterial embolization for hemobilia caused by bile duct tumor thrombi of hepatocellular carcinoma. METHODOLOGY: Between 1993 January and 2000 December, transcatheter arterial embolization was performed in 4 patients with hemobilia and gastrointestinal bleeding from bile duct tumor thrombi of hepatocellular carcinoma. RESULTS: In all 4 patients, transcatheter arterial embolization was successfully performed and resulted in cessation of bleeding. One patient had recurrent hemobilia, which was controlled by another transcatheter arterial embolization. Three patients were discharged from hospital after transcatheter arterial embolization. Patients died of hepatic failure or multiple tumors 5 to 7 months after the onset of hemobilia, although hemobilia had been fully controlled. CONCLUSIONS: Transcatheter arterial embolization seemed to be effective for the control of massive hemobilia caused by bile duct tumor thrombi associated with hepatocellular carcinoma.     

Obstructive jaundice secondary to hepatocellular carcinoma rupture into the common bile duct: choledochoscopic findings

BACKGROUND/AIMS: Hepatocellular carcinoma presenting as obstructive jaundice caused by floating tumor debris in the common bile duct is rare. We report choledochoscopic findings in this rare condition. METHODOLOGY: From January 1981 to December 1995, 28 patients received surgical treatment for obstructive jaundice secondary to hepatocellular carcinoma rupture into the common bile duct. Among them, intra-operative choledochoscopy was performed in 18 patients. RESULTS: Choledochoscopic findings revealed tumor thrombus and an intraluminal yellowish nodular mass in all patients, blood clots in the bile duct in 8 patients, and the appearance of acute erythematous cholangitis in 4 patients. Choledochoscopy revealed that the site of hepatoma rupture was from the right intrahepatic duct in 9 patients, from the left hepatic duct in 7 patients, and from the hepatic hilum in 2 patients. Choledochoscopically guided hepatic resection was performed in 4 patients. CONCLUSIONS: Intra-operative choledochoscopy reveals the characteristic finding of an intraluminal yellowish nodular mass in patients with malignant obstruction of the bile duct due to hepatocellular carcinoma. Hepatic resection with a free margin of the involved hepatic duct can be achieved by a choledochoscopically guided operation.     

Hepatocellular carcinoma with bile duct thrombi: analysis of surgical treatment

BACKGROUND/AIMS: To summarize the experience of surgical intervention for hepatocellular carcinoma with bile duct thrombi, and to evaluate the influence on prognosis. METHODOLOGY: From 1994 to 2002, 15 patients with hepatocellular carcinoma and bile duct thrombi who underwent surgical intervention were retrospectively analyzed. The operative procedures included hepatectomy with removal of bile duct thrombi (n=7), hepatectomy combined with extrahepatic bile duct resection (n=4), thrombectomy through choledochotomy (n=3), and piggyback orthotopic liver transplantation (n=1). RESULTS: The 1- and 3-year survival rates were 73.3% and 40%, respectively. Two patients survived over 5 years. There were no significant differences in the survival rates between patients with and without obstructive jaundice (P>0.05). The survival rate of patients with portal vein invasion was significantly lower than for those without portal vein invasion (P<0.05). CONCLUSIONS: Surgical intervention was effective for patients with hepatocellular carcinoma and bile duct thrombi. Operation for recurrent intrahepatic tumor can prolong the survival period. Liver transplantation is a new operative procedure worthy of investigation.     

Recurrent fibrolamellar hepatocellular carcinoma with biliary invasion: Successful resection

A jaundiced 17-year-old man was diagnosed as having a local recurrence of fibrolamellar hepatocellular carcinoma 2 years and 4 months after left hepatic trisegmentectomy with total caudate lobectomy had been performed. The patient had a tumor occupying the upper part of the extrahepatic and intrahepatic bile ducts. Complete resection of the recurrent tumor was carried out. The patient remains well 3 years after the second surgery. Fibrolamellar hepatocellular carcinoma, a rare type of liver cancer, is a well defined disease entity with distinct clinical and histopathological features and a favorable prognosis. The good prognosis seems to warrant aggressive surgical intervention in patients with recurrences. Therefore, additional surgery for tumor recurrence should be considered. To our knowledge, this is the first report of a case in which a recurrent tumor of fibrolamellar hepatocellular carcinoma invaded the entire bile duct wall was successfully resected.     

Common bile duct blood clot: an unusual cause of ductal filling defects for calculi

We report a case of obstructive jaundice caused by a blood clot in the common bile duct in a 75-year-old man with cirrhosis. Five years prior to his admission, he had undergone a left hepatectomy for hepatocellular carcinoma. At the present admission, he appeared icteric, and endoscopic retrograde cholangiography revealed filling defects in the common bile duct. Choledochotomy was therefore performed for possible common duct stones, and exploration of the duct showed blood clot casts filling the duct. The casts were easily removed, and the patient's postoperative course was uneventful. However, he developed ascites and jaundice 1 month later and died of liver failure approximately 3 months after undergoing the choledochotomy. Autopsy revealed hemorrhagic necrosis in the proximal intrahepatic duct of the posterior segment, which was considered to be the cause of the observed hemobilia, as well as the blood clot in the common bile duct at surgery. We report this rare case and discuss the cause of hemobilia. Received: March 27, 1998/Accepted: November 27, 1998     

Extrahepatic intraductal ectopic hepatocellular carcinoma:bile duct filling defect

BACKGROUND:Obstructive jaundice caused by an intraductal hepatocellular carcinoma is a rare initial symptom.We report a rare case of an extrahepatic icteric type hepatocellular carcinoma.METHODS:A 75-year-old patient was admitted to our hospital because of obstructive jaundice 3 months after resection of multilocular hepatocellular carcinoma.A postoperative bile leakage was treated by placement of a decompressing stent in the common bile duct.Endoscopic retrograde choledochoscopy showed extended blood clots...     

胆管癌栓致阻塞性黄疸9例外科治疗分析

目的探讨胆管癌栓致阻塞性黄疸外科治疗情况及治疗效果。方法对1990年2月至2002年8月间收治的9例原发性肝癌及胆管癌合并胆管癌栓患者的外科治疗情况进行回顾性分析和总结。结果4例行原发肿瘤及胆管癌栓根治切除术;5例行姑息性胆管癌栓清除术加T管引流术。5例患者经胆管切开癌栓清除术后黄疸症状及体征缓解1～4月,平均生存期4—6月;4例患者经左肝叶切除术或胆管癌根治术后1．5—2年内复发或远处转移。结论胆管癌栓致阻塞性黄疸并非手术治疗的禁忌,施行外科手术解决梗阻可能是一种积极的治疗方法。     

Carcinoma of cystic duct leading to obstructive jaundice

Summary Twenty-one cases of primary carcinoma of the cystic duct have been reported in the literature. Most cases were characterized by a hydrops or cholecystitis, whereas only two patients presented with jaundice. To our knowledge, this is only the third case of obstructive jaundice caused by a primary cystic duct carcinoma. The patient was treated by cholecystectomy with resection of the cystic duct tumor and a portion of the common bile duct. Reconstruction was performed by a Roux-en-Y choledocojejunostomy.     

Ectopic hepatocellular carcinoma arising in the bile duct

We report a case of ectopic hepatocellular carcinoma arising in the bile duct. A 72‐year‐old woman was transferred to our hospital with fever, abdominal pain, and jaundice. Contrast‐enhanced computed tomography revealed a round mass, measuring 25 mm in diameter, in the bile duct. The mass was causing obstructive jaundice. Endoscopic retrograde cholangiography showed a 27 mm × 21‐mm round defect in the superior bile duct. These findings led to a diagnosis of bile duct tumor, and the patient underwent extrahepatic bile duct resection and biliary reconstruction. Gross examination of the tumor showed a fibrous capsule and a stalk arising from the bile duct mucosa. The tumor was diagnosed histopathologically as well‐differentiated hepatocellular carcinoma arising in the bile duct.     

Obstructive jaundice caused by hepatocellular carcinoma report of three cases

A cholestatic syndrome secondary to extrahepatic biliary obstruction as the presenting manifestation of hepatocellular caroinoma is aescribed in three cases. The mechanism is related to the invasion of intrahepatic bile ducts by the carcinoma. The consequent mechanical obstruction is due to either a continuous distally growing tumor cast of the biliary tree, distal migration of a necrotic tumor fragment, or hemobilia. In the cirrhotic patient with a predisposition for the deyelopment of liver cancer, the physician should be aware of the presentation with obstructive jaundice as a mechanical complication of hepatocellular carcinoma     

Intraductal polypoid growth variant of pancreatic acinar cell carcinoma metastasizing to the intrahepatic bile duct 6 years after surgery: A case report and literature review

We present the first reported case of intraductal polypoid growth (IPG) variant of pancreatic acinar cell carcinoma (ACC) metastasizing to the intrahepatic bile duct. A 58-year-old Japanese woman had previously presented with obstructive jaundice and a 7.0 cm mass in the pancreatic head. She underwent biliary drainage for 2 months followed by pancreatectomy. Histological examination revealed a carcinoma with acinar pattern, immunohistochemically positive for trypsin, and acinar cell carcinoma was diagnosed. IPGs were prominent in the main pancreatic duct and its tributaries, extending into the intrapancreatic bile duct with tumor casts in the lumen. Imaging examinations 6 years later revealed a growing lesion within the intrahepatic bile duct. Needle biopsy examination suggested metastasis of ACC, and she underwent chemoradiation therapy and partial hepatectomy. Histological examination demonstrated ACC confined to the intrahepatic bile duct. The localization of metastasis and slow growth may indicate indolent biologic behavior of the IPG variant.     

Biliary migration of hepatocellular carcinoma fragment after transcatheter arterial chemoembolization therapy

Occasional side-effects of transcatheter arterial chemoembolization therapy in hepatocellular carcinoma are essentially related to tissue necrosis. We report the case of a patient with hepatocellular carcinoma who experienced an acute common bile duct obstruction a few weeks after such a procedure, in the absence of obvious biliary tract invasion. An endoscopic sphincterotomy relieved the obstruction. At histology, the intra-biliary material was identified as a fragment of hepatocellular carcinoma. We discuss the causes of obstructive jaundice in the setting of hepatocellular carcinoma as well as in the specific situation of transcatheter arterial chemoembolization therapy.     

Resection of an icteric type hepatoma with tumor thrombi filling the right posterior bile duct

A 67-year-old male with jaundice was found to have hepatocellular carcinoma in the right hepatic lobe and tumor thrombi in the common hepatic duct. Physicians initially considered the tumor unresectable, and treated the patient with transcatheter arterial infusion chemotherapy and biliary endoprosthesis. The patient developed a liver abscess after the second transcatheter arterial infusion, and the physicians consulted our department for another form of therapy. Percutaneous transhepatic biliary drainage was performed to relieve revived obstructive jaundice. Cholangiography revealed tumor thrombi extending through the right posterior segmental bile duct into the common hepatic duct. Most biliary branches of the caudate lobe joined with the left lateral posterior segmental branch. Arterial and portal venous branches of the caudate lobe were not involved. Right hepatic lobectomy and extrahepatic bile duct resection were performed 1 year after initial diagnosis. On histologic examination, the epithelium of the right posterior segmental bile duct, which was filled with the tumor thrombi, was not detected. The patient is alive without recurrence 24 months after surgery. Careful investigation of biliary branches of the caudate lobe on cholangiography is essential to determine the necessity of caudate lobectomy in patients with hepatocellular carcinoma and tumor thrombi filling the right posterior segmental bile duct.     

108例阻塞性黄疸的超声诊断分析

目的 探讨超声在阻塞性黄疸诊断中的价值.方法 对我院2004-2007年收治并手术的108例阻塞性黄疸患者的超声声像图进行回顾性分析和总结.结果 阻塞性黄疸超声诊断与手术病理结果符合102例(94.4%),其中胆管结石65例,诊断符合率100%;胆管狭窄2例,诊断符合率66.6%;胰腺炎1例,诊断符合率50.0%;胆囊炎(向后压迫)3例,诊断符合率100%;胰头癌14例,诊断符合率87.5%;壶腹癌11例,诊断符合率91.7%;胆管癌6例,诊断符合率85.7%.结论 超声诊断阻塞性黄疸与手术病理结果符合率高,可作为阻塞性黄疸检查的首选方法,结合临床可提高诊断率.     

Pancreatic tuberculosis with obstructive jaundice—a case report

Isolated pancreatic tuberculosis (TB) is very rare and its treatment somewhat controversial. We report a case of pancreatic TB diagnosed as pancreatic carcinoma. An 82-yr-old man presented with right upper abdominal pain and obstructive jaundice, without fever or weight loss. Ultrasonography, computed tomography, and endoscopic retrograde cholangiopancreatography showed a mass lesion in the pancreatic head, which caused stricturing of the distal common bile duct and pancreatic duct in the head of the gland. As malignancy was suspected, he underwent a Whipple procedure (pancreaticoduodenectomy). Histological examination of the resection specimen disclosed typical features of tuberculosis in the pancreatic head, lymph nodes, and at the ampulla of Vater. The rest of the abdominal cavity was unremarkable. After receiving antimicrobial therapy for tuberculosis for 6 months, he remains well, without jaundice or a recurrent mass visible by ultrasound.     

Carcinoma in situ arising in a tubulovillous adenoma of the distal common bile duct： A case report

Tubulovillous adenomas are common in the colon and rectum, but are rare in the common bile duct. Biliary adenomas may produce obstructive jaundice, which can be easily confused with a malignant neoplasm or stone. We report a case of a carcinoma in situ arising in a tubulovillous adenoma of the distal common bile duct causing obstructive jaundice. A 55-year-old male presented with a 10-d history of pruritus and progressive jaundice. Abdominal sonography and computed tomography showed a mass in the distal common bile duct. Endoscopic retrograde cholangiopancreatography showed luminal narrowing of the bile duct due to a polypoid mass. Positron emission tomography demonstrated no abnormal uptake. It was thought that this mass was a malignant tumor, thus a pylorus-preserving panceaticoduodenectomy was performed. The final pathology showed a tubulovillous adenoma with carcinoma in situ of the distal common bile duct. At follow-up 8 mo later, endoscopy showed multiple polyps in the rectum, colon and stomach. The polyps were removed by endoscopic mucosal resection and shown to be tubular adenomas with high grade dysplasia. Biliary adenomas require careful follow-up for early detection of recurrence and malignant transformation.     

Periampullary choledochoduodenal fistula in ampullary carcinoma

Most patients with ampullary carcinoma have obstructive jaundice without cholangitis. We experienced a patient with ampullary carcinoma who presented with obstructive jaundice and cholangitis, probably because of an accompanying periampullary choledochoduodenal fistula. A 77-year-old Japanese man had jaundice, high fever, and upper abdominal pain and was diagnosed, at another hospital, with obstructive cholangitis. On admission to our hospital, his symptoms and signs had subsided spontaneously. Abdominal ultrasonography showed cholecystolithiasis and dilatation of the common bile duct. Duodenoscopy showed an ulcerating tumor at the oral prominence of the ampulla of Vater and a periampullary choledochoduodenal fistula at the bottom of the ulcer. Biopsy from the fistula showed well differentiated adenocarcinoma. With a diagnosis of ampullary carcinoma with fistula formation, the patient underwent pylorus-preserving pancreatoduodenectomy. The diagnosis was confirmed by histology. This communication presents a unique case of ampullary carcinoma that caused obstructive jaundice, which subsided spontaneously but was associated with cholangitis caused by the divergent effects of the periampullary choledochoduodenal fistula formed by the carcinoma.     

Rupture of the hepatic artery after left hemihepatectomy for hilar bile duct carcinoma

Hilar bile duct carcinoma has a poor prognosis, but this has been improved in recent years by an aggressive surgical approach. We treated a 73-year-old woman who had obstructive jaundice due to bile duct carcinoma at the hepatic hilum. The jaundice decreased after percutaneous transhepatic biliary drainage. The tumor was resected with the left and caudate lobe of the liver and a part of portal vein. The right hepatic artery was located behind the common hepatic duct, and was suspected to be invaded by the tumor. We dissected the tumor from the arterial wall without carrying out combined resection of the hepatic artery. On the 6th postoperative day, the hepatic artery ruptured and the patient suffered hypovolemic shock. Resection of the hepatic artery and reconstruction were done, but the patient died 2 days later. Histological examination of the resected artery showed that the tumor had been curatively removed by dissection and that no tumor remained at the arterial wall. The rupture of the right hepatic artery was thought to have been caused by damage to the wall during the dissection procedure.     

Cholestatic hepatocellular carcinoma diagnosed by deposits of Lipiodol and treated by combination of endoscopic retrograde biliary drainage and transcatheter arterial embolization

Cholestatic hepatocellular carcinoma, which grows into the bile duct and causes obstructive jaundice, is rare and difficult to diagnose. A case is presented in which cholestatic hepatocellular carcinoma was detected by deposit of Lipiodol. This is also the first case that was successfully treated by endoscopic retrograde biliary drainage and transcatheter arterial embolization.