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V V, S Kumar N, Khan O, Azharuddin SK. Giant Choledocholithiasis With Choledochal Cyst: A Report of a Rare Case. Cureus 2024; 16:e64306. [PMID: 39130959 PMCID: PMC11316851 DOI: 10.7759/cureus.64306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
A giant common bile duct (CBD) calculus is a rare occurrence, and the presence of a giant calculus within a choledochal cyst (CDC) is even more unusual. In this case report, we detail an instance of a giant CBD calculus measuring 7 cm x 3 cm found within a CDC, accompanied by multiple tiny calculi. Magnetic resonance cholangiopancreatography (MRCP) revealed the dilation of the bi-lobar intrahepatic biliary radical (IHBR) and the CBD. A large T2 hypointense and T1 hyperintense calculus occupied the dilated CBD and common hepatic duct (CHD), extending into the left hepatic duct (LHD) and right hepatic duct (RHD). There was a possibility of type 1c CDC with cystolithiasis, hepatolithiasis, and cholelithiasis. The patient underwent open cholecystectomy with choledochotomy, stone retrieval, excision of the CDC, and Roux-en-Y hepaticojejunostomy.
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Affiliation(s)
- Vinay V
- Gastrointestinal Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Nayana S Kumar
- General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Ozair Khan
- General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - S K Azharuddin
- Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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Luo B, Li Z, Zhang K, Wu S, Chen W, Fu N, Yang Z, Hao J. Using deep learning models in magnetic resonance cholangiopancreatography images to diagnose common bile duct stones. Scand J Gastroenterol 2024; 59:118-124. [PMID: 37712446 DOI: 10.1080/00365521.2023.2257825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUNDS AND AIMS Magnetic resonance cholangiopancreatography (MRCP) plays a significant role in diagnosing common bile duct stones (CBDS). Currently, there are no studies to detect CBDS by using the deep learning (DL) model in MRCP. This study aimed to use the DL model You Only Look Once version 5 (YOLOv5) to diagnose CBDS in MRCP images and verify its validity compared to the accuracy of radiologists. METHODS By collecting the thick-slab MRCP images of patients diagnosed with CBDS, 4 submodels of YOLOv5 were used to train and validate the performance. Precision, recall rate, and mean average precision (mAP) were used to evaluate model performance. Analyze possible reasons that may affect detection accuracy by validating MRCP images in 63 CBDS patients and comparing them with radiologist detection accuracy. Calculate the correctness of YOLOv5 for detecting one CBDS and multiple CBDS separately. RESULTS The precision of YOLOv5l (0.970) was higher than that of YOLOv5x (0.909), YOLOv5m (0.874), and YOLOv5s (0.939). The mAP did not differ significantly between the 4 submodels, with the following results: YOLOv5l (0.942), YOLOv5x (0.947), YOLO5s (0.927), and YOLOv5m (0.946). However, in terms of training time, YOLOv5s was the fastest (4.8 h), detecting CBDS in only 7.2 milliseconds per image. In 63 patients the YOLOv5l model detected CBDS with an accuracy of 90.5% compared to 92.1% for radiologists, analyzing the difference between the positive group successfully identified and the unidentified negative group not. The incorporated variables include common bile duct diameter > 1 cm (p = .560), combined gallbladder stones (p = .706), maximum stone diameter (p = .057), combined cholangitis (p = .846), and combined pancreatitis (p = .656), and the number of CBDS (p = .415). When only one CBDS was present, the accuracy rate reached 94%. When multiple CBDSs were present, the recognition rate dropped to 70%. CONCLUSION YOLOv5l is the model with the best results and is almost as accurate as the radiologist's detection of CBDS and is also capable of detecting the number of CBDS. Although the accuracy of the test gradually decreases as the number of stones increases, it can still be useful for the clinician's initial diagnosis.
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Affiliation(s)
- Bo Luo
- Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital, School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, P. R. China
| | - Zhiyuan Li
- Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital, School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, P. R. China
| | - Ke Zhang
- Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital, School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, P. R. China
| | - Sikai Wu
- Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital, School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, P. R. China
| | - Weiwei Chen
- Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital, School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, P. R. China
| | - Ning Fu
- Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital, School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, P. R. China
| | - Zhiming Yang
- Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital, School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, P. R. China
| | - Jingcheng Hao
- Department of Hepatobiliary and Vascular Surgery, The First Affiliated Hospital, School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, P. R. China
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Portincasa P, Di Ciaula A, Bonfrate L, Stella A, Garruti G, Lamont JT. Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations. Intern Emerg Med 2023; 18:1897-1918. [PMID: 37455265 PMCID: PMC10543156 DOI: 10.1007/s11739-023-03355-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy.
| | - Agostino Di Ciaula
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy
| | - Leonilde Bonfrate
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy
| | - Alessandro Stella
- Laboratory of Medical Genetics, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Gabriella Garruti
- Section of Endocrinology, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, Bari, Italy
| | - John Thomas Lamont
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA
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Russo GK, Zaheer A, Kamel IR, Porter KK, Archer-Arroyo K, Bashir MR, Cash BD, Fung A, McCrary M, McGuire BM, Shih RD, Stowers J, Thakrar KH, Vij A, Wahab SA, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Right Upper Quadrant Pain: 2022 Update. J Am Coll Radiol 2023; 20:S211-S223. [PMID: 37236744 DOI: 10.1016/j.jacr.2023.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Acute right upper quadrant pain is one of the most common presenting symptoms in hospital emergency departments, as well as outpatient settings. Although gallstone-related acute cholecystitis is a leading consideration in diagnosis, a myriad of extrabiliary sources including hepatic, pancreatic, gastroduodenal, and musculoskeletal should also be considered. This document focuses on the diagnostic accuracy of imaging studies performed specifically to evaluate acute right upper quadrant pain, with biliary etiologies including acute cholecystitis and its complications being the most common. An additional consideration of extrabiliary sources such as acute pancreatitis, peptic ulcer disease, ascending cholangitis, liver abscess, hepatitis, and painful liver neoplasms remain a diagnostic consideration in the right clinical setting. The use of radiographs, ultrasound, nuclear medicine, CT, and MRI for these indications are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Ihab R Kamel
- Panel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin K Porter
- Panel Vice-Chair, University of Alabama Medical Center, Birmingham, Alabama; Council Steering Committee, ACR
| | | | | | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Alice Fung
- Oregon Health & Science University, Portland, Oregon; Liver Reporting & Data System Technique Working Group
| | - Marion McCrary
- Duke Signature Care, Durham, North Carolina; American College of Physicians
| | - Brendan M McGuire
- University of Alabama at Birmingham, Birmingham, Alabama; Primary care physician
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida; American College of Emergency Physicians
| | - John Stowers
- Oregon Health & Science University, Portland, Oregon; American College of Surgeons
| | | | - Abhinav Vij
- New York University Langone Medical Center, New York, New York
| | - Shaun A Wahab
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Katherine Zukotynski
- McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Shabanzadeh DM, Christensen DW, Ewertsen C, Friis-Andersen H, Helgstrand F, Nannestad Jørgensen L, Kirkegaard-Klitbo A, Larsen AC, Ljungdalh JS, Nordblad Schmidt P, Therkildsen R, Vilmann P, Vogt JS, Sørensen LT. National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society. Scand J Surg 2022; 111:11-30. [PMID: 36000716 DOI: 10.1177/14574969221111027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS). METHODS An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences. RESULTS For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation). CONCLUSIONS Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed. ENDORSEMENT The Danish Surgical Society.
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Affiliation(s)
| | | | - Caroline Ewertsen
- Department of Diagnostic Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Hans Friis-Andersen
- Department of Surgery, Regionshospitalet Horsens, Horsens, DenmarkInstitute for Clinical Medicine, Faculty of Health, University of Aarhus, Aarhus, Denmark
| | | | - Lars Nannestad Jørgensen
- Digestive Disease Center, Surgical Section, Bispebjerg Hospital, Copenhagen, DenmarkInstitute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Anders Christian Larsen
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, DenmarkDepartment of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | | | - Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Copenhagen, Denmark
| | | | - Peter Vilmann
- Institute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DenmarkDepartment of Surgery, Herlev Gentofte Hospital, Herlev, Denmark
| | - Jes Sefland Vogt
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Tue Sørensen
- Digestive Disease Center, Surgical Section, Bispebjerg Hospital, Copenhagen, DenmarkInstitute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Hou JU, Park SW, Park SM, Park DH, Park CH, Min S. Efficacy of an artificial neural network algorithm based on thick-slab magnetic resonance cholangiopancreatography images for the automated diagnosis of common bile duct stones. J Gastroenterol Hepatol 2021; 36:3532-3540. [PMID: 34097761 DOI: 10.1111/jgh.15569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/17/2021] [Accepted: 06/05/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Magnetic resonance cholangiopancreatography (MRCP) can accurately diagnose common bile duct (CBD) stones but is laborious to interpret. We developed an artificial neural network (ANN) capable of automatically assisting physicians with the diagnosis of CBD stones. This study aimed to evaluate the ANN's diagnostic performance for detecting CBD stones in thick-slab MRCP images and identify clinical factors predictive of accurate diagnosis. METHODS The presence of CBD stones was confirmed via direct visualization through endoscopic retrograde cholangiopancreatography (ERCP). The absence of CBD stones was confirmed by either a negative endoscopic ultrasound accompanied by clinical improvements or negative findings on ERCP. Our base networks were constructed using state-of-the-art EfficientNet-B5 neural network models, which are widely used for image classification. RESULTS In total, 3156 images were collected from 789 patients. Of these, 2628 images from 657 patients were used for training. An additional 1924 images from 481 patients were prospectively collected for validation. Across the entire prospective validation cohort, the ANN achieved a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of 93.03%, 97.05%, 97.01%, 93.12%, and 95.01%, respectively. Similarly, a radiologist achieved a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy 91.16%, 93.25%, 93.22%, 90.20%, and 91.68%, respectively. In multivariate analysis, only bile duct diameter > 10 mm (odds ratio = 2.45, 95% confidence interval [1.08-6.07], P = 0.040) was related to ANN diagnostic accuracy. CONCLUSION Our ANN algorithm automatically and quickly diagnoses CBD stones in thick-slab MRCP images, therein aiding physicians with optimizing clinical practice, such as whether to perform ERCP.
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Affiliation(s)
- Jong-Uk Hou
- School of Software, Hallym University, Chuncheon, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Seon Mee Park
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Seonjeong Min
- Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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The Role of Laparoscopic Ultrasonography in the Evaluation of Suspected Choledocholithiasis. A Single-Center Experience. MEDICINA-LITHUANIA 2020; 56:medicina56050246. [PMID: 32443814 PMCID: PMC7279262 DOI: 10.3390/medicina56050246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/02/2022]
Abstract
Background and objectives: Opinions differ regarding the optimal diagnostic methods for patients with suspected choledocholithiasis. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) and compare it to pre-operative magnetic resonance cholangio-pancreatography (MRCP); Materials and Methods: In all patients with suspected choledocholithiasis LUS was performed during laparoscopic cholecystectomy to evaluate biliary stones. According to availability, part of the patients had pre-operative MRCP. Data for diagnostic accuracy and main outcomes were collected prospectively and analyzed retrospectively; Results: Choledocholithiasis was detected in 178 of 297 patients by LUS (59.93%) and in 39 of 87 patients by MRCP (44.8%), p = 0.041. LUS yielded a sensitivity of 99.4%, a specificity of 94.3%, a positive predictive value of 96.1% and a negative predictive value of 99.1%. However, pre-operative MRCP had a sensitivity of 61.7%, a specificity of 92.3%, a positive predictive value of 94.9% and a negative predictive value of 51.1%. Moreover, of the 47 patients with no choledocholithiasis by MRCP, in 23 cases it was later detected by LUS (a false negative MRCP finding—38.3%), p < 0.001. Median duration of hospitalization was significantly shorter in patients evaluated without pre-operative MRCP—8 days (interquartile range – IQR 11–6) vs. 11 days (IQR 14–9), p = 0.001; Conclusions: LUS may reduce the role of pre-operative MRCP and can become a rational alternative to MRCP as a primary imaging technique for the detection of choledocholithiasis.
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Thacoor A, Pike TW, Pathak S, Dixon J, Macutkiewicz C, Smith AM. The role of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy for acute gallstone pancreatitis: is magnetic resonance cholangiopancreatography needed? Ann R Coll Surg Engl 2019; 101:428-431. [PMID: 31155897 DOI: 10.1308/rcsann.2019.0049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Intraoperative cholangiography is sporadically used in patients undergoing laparoscopic cholecystectomy to delineate common bile duct anatomy and exclude retained stones. In patients with acute gallstone pancreatitis, intraoperative cholangiography may reduce the need for preoperative magnetic resonance cholangiopancreatography. MATERIALS AND METHODS A retrospective review of a prospectively collected patient database was undertaken over a 15-year period. The primary objective was to evaluate intraoperative assessment of the common bile duct with intraoperative cholangiography in patients with acute gallstone pancreatitis. RESULTS A total of 2215 patients underwent laparoscopic cholecystectomy between October 1998 and December 2013; 113 patients (of whom 77 were women) with a mean age of 54 years (range 16-88 years) were diagnosed with acute gallstone pancreatitis. Of these, 102 patients (90%) underwent laparoscopic cholecystectomy with intraoperative cholangiography, which was normal in 89 cases. Thirteen patients had choledocholithiasis on intraoperative cholangiography, 11 of whom were managed with concomitant trans-cystic duct exploration and clearance. Two patients required postoperative endoscopic retrograde cholangiopancreatography. CONCLUSIONS In patients diagnosed with acute gallstone pancreatitis, it is reasonable to proceed directly to surgery using intraoperative cholangiography on the same admission as the definitive assessment of the common bile duct. This negates the need for magnetic resonance cholangiopancreatography and can translate into cost savings and reduced length of stay.
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Affiliation(s)
- A Thacoor
- Department of Vascular Surgery, Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - T W Pike
- Department of HPB and Transplant Surgery, Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - S Pathak
- Department of HPB and Transplant Surgery, Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - J Dixon
- School of Medicine, University of Leeds , Leeds , UK
| | - C Macutkiewicz
- Department of HPB Surgery, Manchester University NHS Foundation Trust, Manchester Royal Infirmary, Oxford Road , Manchester , UK
| | - A M Smith
- Department of HPB and Transplant Surgery, Leeds Teaching Hospitals NHS Trust , Leeds , UK
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Portincasa P, Molina-Molina E, Garruti G, Wang DQH. Critical Care Aspects of Gallstone Disease. J Crit Care Med (Targu Mures) 2019; 5:6-18. [PMID: 30766918 PMCID: PMC6369569 DOI: 10.2478/jccm-2019-0003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/08/2019] [Indexed: 12/15/2022] Open
Abstract
Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals. This review deals with the important critical care aspects associated with a gallstone-related disease.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica "A. Murri", Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Bari, Italy
| | - Emilio Molina-Molina
- Clinica Medica "A. Murri", Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Bari, Italy
| | - Gabriella Garruti
- Section of Endocrinology, Department of Emergency and Organ Transplantations, University of Bari "Aldo Moro" Medical School, Piazza G. Cesare 11, 70124Bari, Italy
| | - David Q.-H. Wang
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, "Albert Einstein" College of Medicine, Bronx, NY 10461, USA
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10
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Virzì V, Ognibene NMG, Sciortino AS, Culmone G, Virzì G. Routine MRCP in the management of patients with gallbladder stones awaiting cholecystectomy: a single-centre experience. Insights Imaging 2018; 9:653-659. [PMID: 29978345 PMCID: PMC6206385 DOI: 10.1007/s13244-018-0640-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/25/2018] [Accepted: 05/28/2018] [Indexed: 01/14/2023] Open
Abstract
Objectives To assess the frequency of choledocolithiasis and the role of preoperative laboratory findings, ultrasound (US) and magnetic resonance cholangio-pancreatography (MRCP) in the detection of choledocolithiasis in patients with gallbladder stones awaiting cholecystectomy. Methods A consecutive sample of 104 patients underwent MRCP prior to cholecystectomy. The patients were classified into different groups on the basis of the risk of choledocolithiasis. A specialised doctor with more 10 years of experience performed the US interpretation and a radiologist performed the MRCP interpretation blinded to US or aspartate aminotransferase (AST)/alanine aminotransferase (ALT)/alkaline phosphatase (ALP) results. A chi-square (χ2) test was performed to assess the statistical significance of differences in the frequency of choledocolithiasis based on laboratory findings, choledocal diameter on US and group risk. Results MRCP showed calculi in 7 out of 104 patients (6.7%), with no statistically significant differences between the high/moderate risk and low/no risk groups and between the patients with normal and altered laboratory findings or choledocal diameter on preoperative US. The sensitivity and specificity of AST/ALT [positive predictive value (PPV): 12%; negative predictive value (NPV): 94%], ALP (PPV: 7%; NPV: 94%), total serum bilirubin (PPV: 6%; NPV: 93%) and choledocal diameter (PPV: 20%; NPV: 94%) were, respectively, 28.6 and 94.8%, 85.7 and 17.5%, 14.3 and 93.8%, and 14.3 and 95.9%. Conclusions MRCP is a reliable evaluation for the detection of common bile duct (CBD) stones, reducing the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and US examination. Main messages • MRCP is a non-invasive method for the detection of CBD stones. • Preoperative MRCP reduces the misdiagnosis of retained choledocholithiasis. • Detection of choledocholithiasis is mandatory prior to cholecystectomy to avoid surgical morbidity
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Affiliation(s)
- Valentina Virzì
- Department of Radiology, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | | | - Antonio Salvatore Sciortino
- Department of Surgery, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | - Glenda Culmone
- "Regina Pacis" Clinic, Skema Iniziative Sanitarie, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | - Giuseppe Virzì
- Department of Surgery, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
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Diagnostic value of magnetic resonance cholangiopancreatography to detect bile duct stones in acute biliary pancreatitis. Pancreatology 2018; 18:22-28. [PMID: 29246689 DOI: 10.1016/j.pan.2017.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 12/07/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aims to evaluate the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in detecting common bile duct (CBD) stones in acute biliary pancreatitis (ABP). METHODS The medical records of patients presenting with ABP from January 2008 to July 2013 were reviewed to assess the value of MRCP in detecting CBD stones in ABP. Endoscopic retrograde cholangiopancreatography (ERCP) was used as the reference standard to assess the diagnostic yield of MRCP in detecting choledocholithiasis. When ERCP was unavailable, intraoperative cholangiography or clinical follow-up was used as the reference standard. RESULTS Seventy-eight patients who underwent MRCP were diagnosed with ABP, and thirty of the 78 patients (38%) were confirmed to have CBD stones per the study protocol. The sensitivity of MRCP in detecting CBD stones in ABP was 93.3% compared to 66.7% for abdominal CT (P < 0.008). The overall accuracy of MRCP in detecting choledocholithiasis was 85.9% compared to 74.0% for abdominal CT (P < 0.041). The area under the receiver operating characteristic curve (AUC) of MRCP in detecting CBD stones was 0.882, which was more accurate than the AUC of 0.727 for abdominal CT (P = 0.039). In 38 patients who underwent ERCP, the sensitivity and negative predictive value of MRCP in detecting CBD stones were both 100% regardless of the dilatation of the bile duct (≥7 mm versus < 7 mm). CONCLUSION MRCP is an effective, noninvasive modality to detect CBD stones in ABP and can help identify patients who require ERCP.
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Al-Aubaidi T, Ghadhban BR, Chitheer SS. Does preoperative magnetic resonant cholangiopancreatography (MRCP), improve the safety of laparoscopic cholecystectomy? INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Revzin MV, Scoutt LM, Garner JG, Moore CL. Right Upper Quadrant Pain: Ultrasound First! JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1975-1985. [PMID: 28586152 DOI: 10.1002/jum.14274] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 01/27/2017] [Indexed: 06/07/2023]
Abstract
Acute right upper quadrant (RUQ) pain is a common presenting symptom in emergency departments and outpatient medical practices, and is most commonly attributable to biliary and hepatic pathology. Ultrasound should be used as a first-line imaging modality for the diagnosis of gallstones and cholecystitis, as it allows the differentiation of medical and surgical causes of upper abdominal pathology, and in many circumstances is sufficient to guide patient management. Knowledge of strengths and limitations of ultrasound in the evaluation of RUQ is paramount in correct diagnosis. A spectrum of RUQ pathology for which a RUQ ultrasound examination should reasonably be considered as the initial imaging modality of choice will be reviewed.
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Affiliation(s)
- Margarita V Revzin
- Department of Diagnostic Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Leslie M Scoutt
- Department of Diagnostic Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Joseph G Garner
- Department of Medicine and Infectious Diseases, Hospital of Central Connecticut, New Britain, Connecticut, USA
| | - Christopher L Moore
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
Once considered uncommon, pancreatic diseases are increasingly recognized in the pediatric age group. Acute pancreatitis, acute recurrent pancreatitis, and chronic pancreatitis occur in children with an incidence approaching that of adults. Risk factors are broad, prompting the need for a completely different diagnostic and therapeutic approach in children. Although cystic fibrosis remains the most common cause of exocrine pancreatic insufficiency, other causes such as chronic pancreatitis may be as common as Shwachman Diamond syndrome. Long-term effects of pancreatic diseases may be staggering, as children suffer from significant disease burden, high economic cost, nutritional deficiencies, pancreatogenic diabetes, and potentially pancreatic cancer.
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Affiliation(s)
- Aliye Uc
- Division of Pediatric Gastroenterology, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, BT 1120-C, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Douglas S. Fishman
- Texas Children’s Hospital; Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine
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Abdelaal A, El-Matbouly M, Sulieman I, Elfaki A, El-Bakary T, Abdelaziem S, Gehani S, Toro A, Di Carlo I. Role of intraoperative cholangiography for detecting residual stones after biliary pancreatitis: still useful? A retrospective study. World J Emerg Surg 2017; 12:18. [PMID: 28428811 PMCID: PMC5397714 DOI: 10.1186/s13017-017-0130-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/13/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Intraoperative cholangiography (IOC) may detect residual stones in the common bile duct (CBD) after acute biliary pancreatitis (ABP). The aim of the present study is to analyze the utility of IOC in detecting residual stones in patients undergoing cholecystectomy for ABP and if complications are related with this procedure. METHODS Demographic and clinical factors were assessed in patients with mild ABP who underwent IOC during laparoscopic cholecystectomy. Factors assessed included preoperative size of the CBD on ultrasonography, presence of stones in the gallbladder and the CBD, and IOC results. For the statistical analysis, χ2 or Fisher's exact tests to compare proportions and the nonparametric Mann-Whitney U test for analysis of values with abnormal distribution were used. RESULTS The study included 113 patients, 82 males (72.6%) and 31 females (27.4%), of mean age 46.9 ± 14.7 years (range 18-86 years). All preoperative laboratory indicators were elevated. The group of the patients with stones in the CBD diagnosed by IOC was divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD diagnosed preoperatively with ultrasound. The laboratory tests do not demonstrate difference statistically significative between these two groups. The group of the patients without stones in the CBD diagnosed by IOC was also divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD. Also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significative difference. Most procedures were performed by specialists (64.6%), and all patients underwent IOC. IOC showed stones in 84/113 patients (74.3%). A comparison of patients with and without stones at IOC showed similar mean times from hospitalization to surgery (5.9 days [range 2-12 days] vs. 6.1 days [range 2-23 days]), from surgery until hospital discharge (2.0 days [range 0-4 days] vs. 2.2 days [range 0-11 days]), and overall length of stay (7.9 days [range 3-19 days] vs. 8.3 days [range 3-23 days]) (P > 0.001). CONCLUSIONS IOC is useful to diagnose residual CBD stones, without increasing complications related to the procedure itself.
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Affiliation(s)
- Abdelrahman Abdelaal
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Moamena El-Matbouly
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Ibnouf Sulieman
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Ahmad Elfaki
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Tamer El-Bakary
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Sherif Abdelaziem
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Salahdin Gehani
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Adriana Toro
- Department of Surgery, Barone Romeo Hospital, via Mazzini 14, 98066 Patti, (ME) Italy
| | - Isidoro Di Carlo
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
- Department of Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, Via Santa Sofia 78, 95100 Catania, Italy
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Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis. Gastrointest Endosc 2016; 84:639-45. [PMID: 26975235 DOI: 10.1016/j.gie.2016.02.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 02/28/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The option for performing ERCP and laparoscopic cholecystectomy (LC) for the management of choledocholithiasis in the same operative session is often overlooked. We compared the success, safety, and cost of ERCP and LC when performed in either a single session or in separate sessions. METHODS We conducted a retrospective cohort study at a U.S. tertiary care hospital. We identified patients undergoing ERCP and LC between April 2011 and August 2014 in either a single operative session (n = 33) or in 2 separate sessions within a 30-day period (n = 80). Technical success, total anesthesia duration, operative time, length of hospitalization, cost of care, and morbidity and mortality were evaluated. RESULTS Bile duct clearance was achieved in all patients at ERCP in the same-session cohort. The separate versus single-session groups, respectively, did not differ in terms of total procedure times (mean ± SD = 142 ± 64 vs 142 ± 58 min; t test, P =.98), anesthesia duration (251 ± 64 vs 225 ± 69 min; P =.06), or overall cost (49.3 ± 24.5 vs 42.3 ± 23.2 ×1000 USD; P =.167), but hospitalization was longer in the separate-sessions group (6.2 ± 3.3 vs 4.8 ± 2.6 days; P =.03). The rates of adverse events were similarly low (7% vs 2%, P =.70). CONCLUSIONS Performing single-session ERCP and LC is safe, effective, economically viable, and reduces hospital stay compared with performing ERCP and LC during separate sessions.
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Atstupens K, Plaudis H, Fokins V, Mukans M, Pupelis G. Safe laparoscopic clearance of the common bile duct in emergently admitted patients with choledocholithiasis and cholangitis. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:53-60. [PMID: 27212991 PMCID: PMC4874043 DOI: 10.14701/kjhbps.2016.20.2.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/11/2015] [Accepted: 12/13/2015] [Indexed: 12/18/2022]
Abstract
Backgrounds/Aims Laparoscopic treatment of patients with choledocholithiasis and cholangitis is challenging due to mandatory recovery of the biliary drainage and clearance of the common bile duct (CBD). The aim of our study was to assess postoperative course of cholangitis and biliary sepsis after laparoscopic clearance of the CBD in emergently admitted patients with choledocholithiasis and cholangitis. Methods Emergently admitted patients who underwent laparoscopic clearance of the CBD were included prospectively and stratified in 2 groups i.e., cholangitis positive (CH+) or negative (CH-) group. Patient demographics, comorbidities, preoperative imaging data, inflammatory response, surgical intervention, complication rate and outcomes were compared between groups. Results Ninety-nine of a total 320 patients underwent laparoscopic clearance of the CBD, of which, 60 belonged to the acute cholangitis group (CH+) and 39 to the cholangitis negative group (CH-). Interventions were done on average 4 days after admission, operation duration was 95-105 min, and the conversion rate was 3-7% without differences in the groups. Preoperative inflammatory response was markedly higher in the CH+ group. Inflammation signs on intraoperative choledochoscopy were more evident in patients with cholangitis. Postoperative inflammatory response did not differ between the groups. The overall complication rate was 8.3% and 5.1%, respectively. Laparoscopic clearance of the CBD resulted in 1 lethal case (CH+ group), resulting in 1% mortality rate and a similar 12-month readmission rate. Conclusions Single-stage laparoscopic intraoperative US and choledochoscopy-assisted clearance of the CBD is feasible in emergently admitted patients with choledocholithiasis and cholangitis.
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Affiliation(s)
- Kristaps Atstupens
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
| | - Haralds Plaudis
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
| | - Vladimirs Fokins
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
| | - Maksims Mukans
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
| | - Guntars Pupelis
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
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Shingu Y, Komatsu S, Norimizu S, Taguchi Y, Sakamoto E. Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Endosc 2015; 30:526-531. [DOI: 10.1007/s00464-015-4235-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 05/08/2015] [Indexed: 02/07/2023]
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Chen W, Mo JJ, Lin L, Li CQ, Zhang JF. Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis. World J Gastroenterol 2015; 21:3351-3360. [PMID: 25805944 PMCID: PMC4363767 DOI: 10.3748/wjg.v21.i11.3351] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/26/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in patients with choledocholithiasis.
METHODS: We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane databases for studies reporting on the sensitivity, specificity and other accuracy measures of diagnostic effectiveness of MRCP for detection of common bile duct (CBD) stones. Pooled analysis was performed using random effects models, and receiver operating characteristic curves were generated to summarize overall test performance. Two reviewers independently assessed the methodological quality of studies using standards for reporting diagnostic accuracy and quality assessment for studies of diagnostic accuracy tools.
RESULTS: A total of 25 studies involving 2310 patients with suspected choledocholithiasis and 738 patients with CBD stones met the inclusion criteria. The average inter-rater agreement on the methodological quality checklists was 0.96. Pooled analysis of the ability of MRCP to detect CBD stones showed the following effect estimates: sensitivity, 0.90 (95%CI: 0.88-0.92, χ2 = 65.80; P < 0.001); specificity, 0.95 (95%CI: 0.93-1.0, χ2 = 110.51; P < 0.001); positive likelihood ratio, 13.28 (95%CI: 8.85-19.94, χ2 = 78.95; P < 0.001); negative likelihood ratio, 0.13 (95%CI: 0.09-0.18, χ2 = 6.27; P < 0.001); and diagnostic odds ratio, 143.82 (95%CI: 82.42-250.95, χ2 = 44.19; P < 0.001). The area under the receiver operating characteristic curve was 0.97. Significant publication bias was not detected (P = 0.266).
CONCLUSION: MRCP has high diagnostic accuracy for the detection of choledocholithiasis. MRCP should be the method of choice for suspected cases of CBD stones.
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Bektas H, Duzkoylu Y, Cakar E, Buyukasık K, Colak S. Giant choledochal calculosis: surgical treatment. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2014; 6:536-9. [PMID: 25489567 PMCID: PMC4215492 DOI: 10.4103/1947-2714.143286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Context: Gallstone disease is one of the most common surgical pathologies. Choledocholithiasis may occur in some of these cases and require surgical intervention. Although there are relatively non-invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP), this technique is usually unsuccessful in patients with stones larger than 10 mm. In our case, we aimed to report a giant choledochal stone (15 cm × 4.5 cm), which is rare in surgical practice and our treatment with open surgery. Case Report: The patient was a 59-year-old woman. Magnetic resonance cholangiopancreatography (MRCP) had showed a hydropic gallbladder with an excessively dilated CBD and a 110 mm × 41 mm stone. In the operation, an excessively dilated CBD was seen and after choledochotomy and a very large calculus that filled CBD completely. Choledochotomy incision was carried forward and a T-tube choledochostomy with choledochoduodenostomy (CD) was performed. The patient was discharged without any complications on postoperative 8th day. Conclusion: Benign gallstone disease is a multifactorial process, with risk factors such as obesity, hemolytic diseases, diabetes mellitus, and pregnancy. Risk factors for choledocholithiasis are similar to those for gallstone disease. MRCP is a non-invasive technique in detecting choledocholithiasis. The gold standard intervention for CBD stones is ERCP. Stones in CBD may reach very considerable dimensions without causing serious symptoms. The most common symptom is jaundice. During preoperative radiological examination, giant stones may be interfered with malignancies. Surgeons should obey conventional algorithms in diagnosis and open surgery must be kept in mind in earlier stages without being too insistent on endoscopic interventions.
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Affiliation(s)
- Hasan Bektas
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
| | - Yigit Duzkoylu
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
| | - Ekrem Cakar
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
| | - Kenan Buyukasık
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
| | - Sukru Colak
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
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Signoretti M, Baccini F, Piciucchi M, Iannicelli E, Valente R, Zerboni G, Capurso G, Delle Fave G. Repeated transabdominal ultrasonography is a simple and accurate strategy to diagnose a biliary etiology of acute pancreatitis. Pancreas 2014; 43:1106-1110. [PMID: 25003222 DOI: 10.1097/mpa.0000000000000164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Transabdominal ultrasonography (US) usually reveals diagnosis of biliary acute pancreatitis (AP). Guidelines suggest repeating US in AP patients without cause at first examination. This approach has been poorly investigated, as well as the accuracy of repeated US as compared with that of magnetic resonance cholangiopancreatography. This study aims at evaluating the diagnostic accuracy of repeated US for biliary AP. METHODS The accuracy of each test for diagnosis of biliary AP was evaluated according to the final diagnosis. Comparison between tests was obtained by examining the areas under the receiver operating characteristic curves. RESULTS Among 155 patients, the etiology was biliary in 52% and alcoholic in 20%. The accuracy of the first US alone and of the 2 combined examinations for a biliary etiology were 66% and 83%, respectively. Comparison of receiver operating characteristic curves showed a better performance of repeated US (difference between areas under the curve, 0.135; 95% confidence interval, 0.02-0.24; P = 0.021). Magnetic resonance cholangiopancreatography had high specificity (93%) but low sensitivity (62%), with 76% accuracy. The accuracy of the combination of the 2 US examinations and of elevated alanine transferase was 87%. CONCLUSIONS Repeated US is effective for biliary AP diagnosis. The combination of repeated US examinations and biochemical tests seems an effective approach, whereas magnetic resonance cholangiopancreatography might be restricted to selected cases.
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Affiliation(s)
- Marianna Signoretti
- From the *Digestive and Liver Disease Unit, and †Radiology Unit, University "Sapienza," Sant'Andrea Hospital, Rome, Italy
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[Design of a preoperative predictive score for choledocholithiasis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:511-8. [PMID: 24948445 DOI: 10.1016/j.gastrohep.2014.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/18/2014] [Accepted: 04/24/2014] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Choledocholithiasis is the most common cause of obstructive jaundice and occurs in 5-10% of patients with cholelithiasis. OBJECTIVES To design a preoperative predictive score for choledocholithiasis. MATERIAL AND METHODS A prospective study was carried out in 556 patients admitted to our department for biliary disease. Preoperative clinical, laboratory, and ultrasound variables were compared between patients without choledocholithiasis and 65 patients with this diagnosis. A multivariate logistic analysis was performed to obtain a predictive model of choledocholithiasis, determining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS Predictors of choledocholithiasis were the presence of a prior history of biliary disease (history of biliary colic, acute cholecystitis, choledocholithiasis or acute biliary pancreatitis) (p=0.021, OR=2.225, 95% CI: 1.130-4.381), total bilirubin values >4mg/dl (p=0.046, OR=2.403, 95% CI: 1.106-5.685), alkaline phosphatase values >150mg/dl (p=0.022 income, OR=2.631, 95%: 1.386-6.231), gamma-glutamyltransferase (GGT) values >100mg/dl (p=0.035, OR=2.10, 95% CI: 1.345-5.850), and an ultrasound finding of biliary duct >8mm (p=0.034, OR=3.063 95% CI: 1086-8649). A score superior to 5 had a specificity and PPV of 100% for detecting choledocholithiasis and a score less than 3 had a sensitivity and NPV of 100% for excluding this diagnosis. CONCLUSIONS The preoperative score can exclude or confirm the presence of choledocholithiasis and allows patients to directly benefit from laparoscopic cholecystectomy (LC) or prior endoscopic retrograde cholangiopancreatography (ERCP).
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Li P, Zhang Z, Li J, Jin L, Han W, Zhang J. Diagnostic value of magnetic resonance cholangiopancreatography for secondary common bile duct stones compared with laparoscopic trans-cystic common bile duct exploration. Med Sci Monit 2014; 20:920-6. [PMID: 24894946 PMCID: PMC4061148 DOI: 10.12659/msm.890831] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background The aim of this study was to evaluate the diagnostic potential of magnetic resonance cholangiopancreatography (MRCP) in preoperative patients with secondary common bile duct stones during the application of laparoscopic trans-cystic common bile duct exploration (LTCBDE). Material/Methods The clinical records of 255 patients were retrospectively analyzed. All patients included in the study were examined by MRCP 3 days prior to LTCBDE. Results Secondary bile duct stones were detected in 220 patients using LTCBDE. Of the patients diagnosed by MRCP, 141 were true-positive, 28 were true-negative, 7 were false-positive and 79 were false-negative. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of MRCP for secondary common bile duct stones were 64.09%, 80.00%, 66.27%, 95.27%, and 26.17%, respectively. When the cases with muddy stones were excluded, the outcomes were 80.41%, 79.41%, 69.23%, 94.44%, and 48.21%, respectively. When cases with stones <3 mm (inclusive) in diameter were excluded, the outcomes were 93.75%, 79.41%, 86.27%, 93.75%, and 65.85%, respectively. When cases with stones <5 mm (inclusive) in diameter were excluded, the outcomes were 93.10%, 79.41%, 89.26%, 92.05%, and 81.82%, respectively. Conclusions The effectiveness of preoperative MRCP is overestimated for the diagnosis of secondary common bile duct stones, particularly for muddy and micro-stones.
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Affiliation(s)
- Peixin Li
- Department of Comprehensive Surgery, Medical and Health Center, Beijing Friendship Hospital affiliated to Capital Medical University, Beijing, China (mainland)
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital Affiliated to Capital Medical Universit, Beijing, China (mainland)
| | - Jianshe Li
- Department of General Surgery, Beijing Friendship Hospital Affiliated to Capital Medical Universit, Beijing, China (mainland)
| | - Lan Jin
- Department of General Surgery, Beijing Friendship Hospital Affiliated to Capital Medical Universit, Beijing, China (mainland)
| | - Wei Han
- Department of General Surgery, Beijing Friendship Hospital Affiliated to Capital Medical Universit, Beijing, China (mainland)
| | - Jie Zhang
- Department of Medical Imaging, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China (mainland)
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DuCoin C, Moon RC, Teixeira AF, Jawad MA. Laparoscopic choledochoduodenostomy as an alternate treatment for common bile duct stones after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2014; 10:647-52. [PMID: 24913592 DOI: 10.1016/j.soard.2014.01.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 12/31/2013] [Accepted: 01/06/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), the new gastrointestinal configuration does not permit easy endoscopic access to the biliary system in the standard fashion. Common bile duct (CBD) stones have proved to be a challenge for both the surgeon and the endoscopist in this setting. We shall review our experience with laparoscopic choledochoduodenostomy as a treatment of choledocholithiasis after gastric bypass. METHODS Between January 2000 and July 2012, 3115 patients underwent RYGB at our institution. Patients were included if they had postoperative CBD stones regardless of previous cholecystectomy. Treatment modality was laparoscopic choledochoduodenostomy. A retrospective chart review of a prospectively collected data was completed, noting the outcomes and complications of the procedure. RESULTS Of 3115 patients, 11 patients were included in this study. There were 8 female and 3 male patients with a mean age of 50.5 ± 10.9 (range, 34-66) years. The average time between primary RYGB and choledochoduodenostomy was 39.7 ± 33.8 (range 8-113) months. The average body mass index at primary surgery was 48.2 ± 8.1 (range 38.4-67.4) kg/m(2) and at choledochoduodenostomy was 29.5 ± 6.8 (range 22.7-46.9) kg/m(2). One patient had bile leak that was managed with drain. All patients had resolution of symptoms at a mean follow-up of 24.8 ± 26.9 (range 2-84) months. CONCLUSION This small case series suggests that, in experienced hands, laparoscopic choledochoduodenostomy is an option for safe and effective treatment of choledocholithiasis after gastric bypass.
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Affiliation(s)
- Christopher DuCoin
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida
| | - Rena C Moon
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida
| | - Andre F Teixeira
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida
| | - Muhammad A Jawad
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida.
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Abstract
Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to severe acute illness with a significant risk of death. Urgent endoscopic treatment of acute pancreatitis is considered when there is causal evidence of biliary pancreatitis. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.
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Affiliation(s)
- Vincent C Kuo
- Gastroenterology Fellowship, Methodist Dallas Medical Center, 1441 North Beckley Avenue, Dallas, TX 75203, USA
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Barlow AD, Haqq J, McCormack D, Metcalfe MS, Dennison AR, Garcea G. The role of magnetic resonance cholangiopancreatography in the management of acute gallstone pancreatitis. Ann R Coll Surg Engl 2013; 95:503-6. [PMID: 24112497 PMCID: PMC5827288 DOI: 10.1308/003588413x13629960049036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2013] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The aim of this study was to identify whether magnetic resonance cholangiopancreatography (MRCP) can be used selectively in patients with acute gallstone pancreatitis to detect choledocholithiasis, based on liver function tests (LFTs) and ultrasonography appearance. METHODS All patients admitted between January 2008 and January 2011 with gallstone pancreatitis (amylase >300u/l) who underwent MRCP were included in the study. LFTs and radiology reports were obtained from the respective computer systems. RESULTS Overall, 173 patients with acute gallstone pancreatitis underwent MRCP and 30% (52/173) showed choledocholithiasis. The mean bilirubin level was significantly higher in those with choledocholithiasis (46 ±5μmol/l vs 36 ±3μmol/l, p=0.0388) although there was no significant difference in alkaline phosphatase (276 ±25iu/l vs 229 ±16iu/l, p=0.1154). However, sensitivity of abnormal bilirubin (>21μmol/l) for choledocholithiasis was only 62% and specificity was 41%. Sensitivity of abnormal alkaline phosphatase (>140iu/l) for choledocholithiasis was only 75% and specificity was 37%. There was a significant association between biliary dilatation on ultrasonography and choledocholithiasis on MRCP (p=0.0099) although the sensitivity of biliary dilatation for choledocholithiasis was only 44% and the specificity was 79%. Furthermore, there was no difference in the incidence of choledocholithiasis on MRCP for those patients with persistently deranged LFTs versus those whose LFTs returned to normal (relative risk: 1.07, 95% confidence interval: 0.61-1.89, p=1.00). Overall, 10% of patients with choledocholithiasis on MRCP had entirely normal LFTs on admission and no biliary dilatation or choledocholithiasis on ultrasonography. CONCLUSIONS All patients with acute gallstone pancreatitis should undergo specific imaging, preferably MRCP, to exclude choledocholithiasis as LFTs and ultrasonography are inaccurate in predicting common bile duct stones.
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Affiliation(s)
- A D Barlow
- University Hospitals of Leicester NHS Trust, UK
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Al-Jiffry BO, Elfateh A, Chundrigar T, Othman B, AlMalki O, Rayza F, Niyaz H, Elmakhzangy H, Hatem M. Non-invasive assessment of choledocholithiasis in patients with gallstones and abnormal liver function. World J Gastroenterol 2013; 19:5877-5882. [PMID: 24124333 PMCID: PMC3793142 DOI: 10.3748/wjg.v19.i35.5877] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 04/15/2013] [Accepted: 06/06/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To find a non-invasive strategy for detecting choledocholithiasis before cholecystectomy, with an acceptable negative rate of endoscopic retrograde cholangiopancreatography.
METHODS: All patients with symptomatic gallstones were included in the study. Patients with abnormal liver functions and common bile duct abnormalities on ultrasound were referred for endoscopic retrograde cholangiopancreatography. Patients with normal ultrasound were referred to magnetic resonance cholangiopancreatography. All those who had a negative magnetic resonance or endoscopic retrograde cholangiopancreatography underwent laparoscopic cholecystectomy with intraoperative cholangiography.
RESULTS: Seventy-eight point five percent of patients had laparoscopic cholecystectomy directly with no further investigations. Twenty-one point five percent had abnormal liver function tests, of which 52.8% had normal ultrasound results. This strategy avoided unnecessary magnetic resonance cholangiopancreatography in 47.2% of patients with abnormal liver function tests with a negative endoscopic retrograde cholangiopancreatography rate of 10%. It also avoided un-necessary endoscopic retrograde cholangiopancreatography in 35.2% of patients with abnormal liver function.
CONCLUSION: This strategy reduces the cost of the routine use of magnetic resonance cholangiopancreatography, in the diagnosis and treatment of common bile duct stones before laparoscopic cholecystectomy.
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Planells Roig M, Ponce Villar Ú, Peiró Monzó F, Coret Franco A, Orozco Gil N, Bañuls Matoses Á, Sanchez Aparisi E, Marti Gonzalez L, Caro Martínez F. Biliary Pancreatitis. Liver Function Tests and Common Biliopancreatic Channel Kinetics--Biliopancreatic Reflux. Cir Esp 2013; 93:326-33. [PMID: 24041581 DOI: 10.1016/j.ciresp.2013.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 04/06/2013] [Accepted: 04/09/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the prevalence of biliopancreatic reflux (BPR) in patients with biliary pancreatitis (BP) undergoing elective cholecystectomy with intraoperative cholangiography (IOC) in comparison with a control group of symptomatic cholelithiasis (CG). PATIENTS AND METHODS Retrospective review of 107 consecutive BP cases. BPR was determined by IOC and liver function tests (LFT) were recorded at admission (A), 48hours, and preoperative examination (P). LFT analysis between A and P were analysed between groups with respect to BPR, time interval to cholecystectomy within the same group and by determination of observed value/maximum normal value ratio (OV/MNV). RESULTS BPR incidence was 38.3% in BP in comparison with 5% in CG (p=0.0001) it was independent from interval time to cholecystectomy, in contrast with Odditis, suggesting an anatomical condition for CCBP and a functional one for Odditis. LFT analysis showed no differences in relation to BPR incidence. LFT excluding AP and GGT returned to normal values with significant differences in OV/MNV when BPR was present which points to an increased cholestasis in BPR group. US dilatation of CBD was noted in 10.3% and was associated to CCBP. CONCLUSIONS BPR in BP increases cholestasis and contributes to confusion in the estimation of common bile duct stones increasing ERCP-EE rates. US and biochemical markers of CBDS show a low specificity due to BPR-CCBP which suggests that MRI-cholangiography is a mandatory exploration before ERCP-EE examination.
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Affiliation(s)
- Manuel Planells Roig
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía, Hospital Francisco de Borja, Gandía, Valencia, España.
| | | | - Fabián Peiró Monzó
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía, Hospital Francisco de Borja, Gandía, Valencia, España
| | - Alba Coret Franco
- Servicio de Cirugía, Hospital Francisco de Borja, Gandía, Valencia, España
| | - Natalia Orozco Gil
- Servicio de Cirugía, Hospital Francisco de Borja, Gandía, Valencia, España
| | | | | | - Lidia Marti Gonzalez
- Servicio de Gastroenterología, Hospital Francisco de Borja, Gandía, Valencia, España
| | - Federico Caro Martínez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Francisco de Borja, Gandia, Valencia, España
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Santos JS, Kemp R, Ardengh JC, Elias J. Conservative management of cholestasis with and without fever in acute biliary pancreatitis. World J Gastrointest Surg 2012; 4:55-61. [PMID: 22530079 PMCID: PMC3332222 DOI: 10.4240/wjgs.v4.i3.55] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 12/31/2011] [Accepted: 01/10/2012] [Indexed: 02/06/2023] Open
Abstract
The presence of cholestasis in both mild and severe forms of acute biliary pancreatitis (ABP) does not justify, of itself, early endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (ES). Clinical support treatment of acute pancreatitis for one to two weeks is usually accompanied by regression of pancreatic edema, of cholestasis and by stone migration to the duodenum in 60%-88% of cases. On the other hand, in cases with both cholestasis and fever, a condition usually characterized as ABP associated with cholangitis, early ES is normally indicated. However, in daily clinical practice, it is practically impossible to guarantee the coexistence of cholangitis and mild or severe acute pancreatitis. Pain, fever and cholestasis, as well as mental confusion and hypotension, may be attributed to inflammatory and necrotic events related to ABP. Under these circumstances, evaluation of the bile duct by endo-ultrasonography (EUS) or magnetic resonance cholangiography (MRC) before performing ERC and ES seems reasonable. Thus, it is necessary to assess the effects of the association between early and opportune access to the treatment of local and systemic inflammatory/infectious effects of ABP with cholestasis and fever, and to characterize the possible scenarios and the subsequent approaches to the common bile duct, directed by less invasive examinations such as MRC or EUS.
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Affiliation(s)
- José Sebastião Santos
- José Sebastião Santos, Rafael Kemp, José Celso Ardengh, Division of Digestive Surgery, Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo, CEP 14049-900 São Paulo, Brazil
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Abstract
Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.
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Güngör B, Cağlayan K, Polat C, Seren D, Erzurumlu K, Malazgirt Z. The predictivity of serum biochemical markers in acute biliary pancreatitis. ISRN GASTROENTEROLOGY 2010; 2011:279607. [PMID: 21991501 PMCID: PMC3168389 DOI: 10.5402/2011/279607] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 11/24/2010] [Indexed: 12/11/2022]
Abstract
Background and Aim. There are no accurate methods of differentiating acute biliary pancreatitis. Obstructions of biliary ducts, idiopathic pancreatitis may be related with biliary origin which needs identification for acute treatment. We searched for the predictivity of biochemical markers in early acute biliary pancreatitis. Patients and Methods. Serum levels of AST (Aspartate Transaminase),ALT (Alanine Transaminase), ALP (Alkaline Phosphatase), GGT (Gamma Glutamyl Transferase), total bilirubin, direct bilirubin, LDH (Lactate Dehydrogenase), amylase, lipase, CRP (C-Reactive Protein) and WBC (White Blood Cell) were measured in 157 patients with acute pancreatitis. Biliary and nonbiliary pancreatitis were differentiated by Magnetic Resonance Cholangiopancreatography (MRCP), Endoscopic Retrograde Cholangiopancreatography (ERCP), Intraoperative Cholangiopancreatography (IOC). Cut-off points of admission biochemical markers with sensitivity, specifity, positive predictive value and negative predictive value were determined after identification of significant variables. Receiver Operator Curves were plotted for each biochemical marker. Results. Serum Alkaline Phosphatase, total bilirubin, direct bilirubin, amylase and lipase levels were significantly higher in biliary pancreatitis with a positive predictive value of 80.8%, 83.9%, 81.6%, 78.8%, 79.7%. Conclusion. Increased Alkaline Phosphatase,total bilirubin, direct bilirubin, amylase and lipase levels may be used in prediction of biliary pancreatitis.
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Affiliation(s)
- Bülent Güngör
- Department of Surgery, Faculty of Medicine, Ondokuz Mayıs University, 55139 Samsun, Turkey
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Abstract
Establishing a biliary etiology in acute pancreatitis is clinically important because of the potential need for invasive treatment, such as endoscopic retrograde cholangiopancreatography. The etiology of acute biliary pancreatitis (ABP) is multifactorial and complex. Passage of small gallbladder stones or biliary sludge through the ampulla of Vater seems to be important in the pathogenesis of ABP. Other factors, such as anatomical variations associated with an increased biliopancreatic reflux, bile and pancreatic juice exclusion from the duodenum, and genetic factors might contribute to the development of ABP. A diagnosis of a biliary etiology in acute pancreatitis is supported by both laboratory and imaging investigations. An increased serum level of alanine aminotransferase (>1.0 microkat/l) is associated with a high probability of gallstone pancreatitis (positive predictive value 80-90%). Confirmation of choledocholithiasis is most accurately obtained using endoscopic ultrasonography or magnetic resonance cholangiopancreatography. This Review discusses the pathogenesis of ABP and the clinical techniques used to predict and establish a biliary origin in patients with suspected ABP.
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Mohandas S, John AK. Role of intra operative cholangiogram in current day practice. Int J Surg 2010; 8:602-5. [PMID: 20673816 DOI: 10.1016/j.ijsu.2010.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2010] [Accepted: 06/15/2010] [Indexed: 12/19/2022]
Abstract
The role of Intra Operative Cholangiogram during laparoscopic cholecystectomy remains controversial. This review discusses the modalities used in the pre- and peri-operative assessment of Common Bile Duct. It also discusses the advantages and disadvantages of selective and routine IOC. In this review we explore the role of Intra Operative Cholangiogram in current day practice.
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Affiliation(s)
- Shailesh Mohandas
- Hepatobiliary and Pancreatic Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, United Kingdom.
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The value of pre-operative magnetic resonance cholangiopancreatography (MRCP) in management of patients with gall stones. Int J Surg 2010; 8:342-5. [PMID: 20450989 DOI: 10.1016/j.ijsu.2010.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 03/11/2010] [Accepted: 03/22/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To analyze influence of pre-operative MRCP on the management of patients with gall stones. PATIENTS & METHODS This prospective randomized study was carried on 250 patients who underwent laparoscopic cholecystectomy within 3 years. In group I, pre-operative MRCP was performed in 125 patients with age range of 18-62 years. Group II included 125 patients managed by laparoscopic cholecystectomy without doing pre-operative MRCP with age range of 21-65 years. RESULTS In group I; pre-operative MRCP screening revealed clinically silent CBD stones in 5 patients (4%), accessory cystic duct in 2 (1.6%), abnormal insertion of cystic duct in 1 (0.8%). Postoperatively, bile duct injury was inflected in 1 patient in group I. On the other hand, there were 2 patients with bile duct injury and 5 patients with residual stones in group II. There was a statistically significant increase of post-operative complications in group II (p <or= 0.5). CONCLUSIONS MRCP is diagnostically useful in management of patients with gall stones prior to laparoscopic cholecystectomy and its routine use can reduce the incidence of post-operative complications.
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Abstract
The detection and management of bile duct stones in acute pancreatitis have improved considerably. Now it is possible to identify non-invasively stones in the duct before definitive treatment. Recently new evidence has confirmed that the indication for early endoscopic sphincterotomy should be severe acute pancreatitis with evidence of bile duct obstruction. This review analyses the evidence that defines current best practice in this area. and IAP.
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Affiliation(s)
- Colin Johnson
- University Surgical Unit, Southampton General Hospital, Southampton, UK.
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Kiriyama S, Gabata T, Takada T, Hirata K, Yoshida M, Mayumi T, Hirota M, Kadoya M, Yamanouchi E, Hattori T, Takeda K, Kimura Y, Amano H, Wada K, Sekimoto M, Arata S, Yokoe M, Hirota M. New diagnostic criteria of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:24-36. [PMID: 20012328 DOI: 10.1007/s00534-009-0214-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/25/2022]
Abstract
Practical guidelines for the diagnosis of acute pancreatitis are presented so that a rapid and adequate diagnosis can be made. When acute pancreatitis is suspected in patients with acute onset of abdominal pain and tenderness mainly in the upper abdomen, the diagnosis of acute pancreatitis is made on the basis of elevated levels of pancreatic enzymes in the blood and/or urine. Furthermore, other acute abdominal diseases are ruled out if local findings associated with pancreatitis are confirmed by diagnostic imaging. According to the diagnostic criteria established in Japan, patients who present with two of the following three manifestations are diagnosed as having acute pancreatitis: characteristic upper abdominal pain, elevated levels of pancreatic enzymes, and findings of ultrasonography (US), CT or MRI suggesting acute pancreatitis. Detection of elevated levels of blood pancreatic enzymes is crucial in the diagnosis of acute pancreatitis. Measurement of blood lipase is recommended, because it is reported to be superior to all other pancreatic enzymes in terms of sensitivity and specificity. For measurements of the blood amylase level widely used in Japan, it should be cautioned that, because of its low specificity, abnormal high values are also often obtained in diseases other than pancreatitis. The cut-off level of blood pancreatic enzymes for the diagnosis of acute pancreatitis is not able to be set because of lack of sufficient evidence and consensus to date. CT study is the most appropriate procedure to confirm image findings of acute pancreatitis. Elucidation of the etiology of acute pancreatitis should be continued after a diagnosis of acute pancreatitis. In the process of the etiologic elucidation of acute pancreatitis, judgment whether it is gallstone-induced or not is most urgent and crucial for deciding treatment policy including the assessment of whether endoscopic papillary treatment should be conducted or not. The diagnosis of gallstone-induced acute pancreatitis can be made by combining detection of elevated levels of bilirubin, transamylase (ALT, AST) and ALP detected by hematological examination and the visualization of gallstones by US.
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Affiliation(s)
- Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, 4-86 Minaminokawa, Ogaki, Gifu, 503-0864, Japan.
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Various techniques for the surgical treatment of common bile duct stones: a meta review. Gastroenterol Res Pract 2009; 2009:840208. [PMID: 19672460 PMCID: PMC2722154 DOI: 10.1155/2009/840208] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Accepted: 05/25/2009] [Indexed: 02/08/2023] Open
Abstract
Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.
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Samaraee AA, Khan U, Almashta Z, Yiannakou Y. Preoperative diagnosis of choledocholithiasis: the role of MRCP. Br J Hosp Med (Lond) 2009; 70:339-43. [DOI: 10.12968/hmed.2009.70.6.339] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Ahmad Al Samaraee
- Senior Clinical Fellow in the Department of General Surgery, Queen Elizabeth Hospital, Gateshead NE9 6SX
| | - Usman Khan
- Research Fellow in Gastroenterology, University Hospital of North Durham, Durham
| | - Zaid Almashta
- Senior Clinical Fellow in Accident and Emergency, Queen Mary's Hospital, Sidcup, Kent
| | - Yan Yiannakou
- Consultant Gastroenterologist, University Hospital of North Durham, Durham
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Natural progression of biochemical markers of biliary tract obstruction in patients with gallstone pancreatitis. Gastroenterol Res Pract 2009; 2009:820749. [PMID: 19503827 PMCID: PMC2686090 DOI: 10.1155/2009/820749] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Revised: 03/09/2009] [Accepted: 04/12/2009] [Indexed: 11/19/2022] Open
Abstract
The presenting pattern and natural progression of biochemical markers of biliary tract obstruction in patients with gallstone pancreatitis have not been elucidated. We analyzed serial values of bilirubin levels following admission to discharge in 143 patients. Ninety-four of patients demonstrated a Decrescendo (falling) pattern of bilirubin levels from admission until normalization at 21 hours (median). Forty-nine patients demonstrated a Crescendo-Decrescendo (initially rising) pattern with peak levels of bilirubin occurring at 39 hours after admission followed by a subsequent normalization after a median of 119 hours. Patients in the Decrescendo group were significantly younger (33 versus 41 years, P = .02) and more patients had experienced symptoms for greater than 48 hours (65% versus 47%, P = .05). Ten percent of patients in the Decrescendo group and 29% of patients in the Crescendo-Decrescendo group underwent ERCP (P = .02). Normalization of biochemical markers after ERCP was significantly delayed in both groups compared to no ERCP. Older patients present earlier, with higher bilirubin levels and normalize slower than younger patients, perhaps due to fibrosis of the ampulla and decreased compliance of the common bile duct. Patients who disobstruct spontaneously (90%) normalize quicker than patients undergoing ERCP.
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40
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Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy? Langenbecks Arch Surg 2008; 394:1005-10. [PMID: 19084990 DOI: 10.1007/s00423-008-0447-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2008] [Accepted: 09/16/2008] [Indexed: 12/20/2022]
Abstract
PURPOSE We investigated routinely the bile ducts by magnetic resonance cholangiopancreaticography (MRCP) prior to cholecystectomy. The aim of this study was to analyze the rate of clinically inapparent common bile duct (CBD) stones, the predictive value of elevated liver enzymes for CBD stones, and the influence of the radiological results on the perioperative management. METHODS In this prospective study, 465 patients were cholecystectomized within 18 months, mainly laparoscopically. Preoperative MRCP was performed in 454 patients. RESULTS With MRCP screening, clinically silent CBD stones were found in 4%. Elevated liver enzymes have only a poor predictive value for the presence of CBD stones (positive predictive value, 21%; negative predictive value, 96%). Compared to the recent literature, the postoperative morbidity in this study was low (0 bile duct injury, 0.4% residual gallstones). CONCLUSIONS Although MRCP is diagnostically useful in the perioperative management in some cases, its routine use in the DRG-era may not be justified due to the costs.
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Navarro S, Amador J, Argüello L, Ayuso C, Boadas J, de Las Heras G, Farré A, Fernández-Cruz L, Ginés A, Guarner L, López Serrano A, Llach J, Lluis F, de Madaria E, Martínez J, Mato R, Molero X, Oms L, Pérez-Mateo M, Vaquero E. [Recommendations of the Spanish Biliopancreatic Club for the Treatment of Acute Pancreatitis. Consensus development conference]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:366-87. [PMID: 18570814 DOI: 10.1157/13123605] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Salvador Navarro
- Servicio de Gastroenterología, Institut de Malalties Digestives i Metabóliques, Hospital Clínic, Barcelona, Spain.
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Tseng CW, Chen CC, Chen TS, Chang FY, Lin HC, Lee SD. Can computed tomography with coronal reconstruction improve the diagnosis of choledocholithiasis? J Gastroenterol Hepatol 2008; 23:1586-9. [PMID: 18713297 DOI: 10.1111/j.1440-1746.2008.05547.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Many technical developments of computed tomography (CT) made in recent years have improved imaging quality. However, the diagnostic efficacy of CT with coronal reconstruction for choledocholithiasis remains uncertain. This study aimed to investigate if CT with coronal reconstruction can aid in the diagnosis of choledocholithiasis. METHODS Two hundred and sixty-six patients with clinically suspected choledocholithiasis undergoing abdominal CT before endoscopic retrograde cholangiopancreatography were recruited. Among them, 163 patients confirmed with choledocholithiasis were divided into three groups: group 1, 92 patients undergoing CT using 5-mm thick sections with coronal reconstruction; group 2, 32 patients undergoing CT using 5-mm thick sections without coronal reconstruction; and group 3, 39 patients undergoing CT using 7-mm thick sections without coronal reconstruction. The diagnostic rate of CT for choledocholithiasis, the stone size and biochemical data among the three groups were analyzed. RESULTS The sensitivity and specificity of CT in diagnosing choledocholithiasis were 77.3% and 72.8%. There was no significant difference of CT diagnostic rate among the three groups (75.0%, 81.2% and 79.5%, respectively). The diameter of common bile duct (CBD), size of CBD stones and white cell count showed significant differences between CT true-positive and false-negative cases in group 1 patients. The CT diagnostic rate was significantly lower in patients with choledocholithiasis of less than 5 mm than in patients with choledocholithiasis of 5 mm or more (56.5% vs 81.2%). CONCLUSION The coronal reconstruction of CT imaging did not increase its diagnostic efficacy on choledocholithiasis. The stone size affects the diagnostic rate of abdominal CT for detecting choledocholithiasis.
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Affiliation(s)
- Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
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Ito K, Ito H, Tavakkolizadeh A, Whang EE. Is ductal evaluation always necessary before or during surgery for biliary pancreatitis? Am J Surg 2008; 195:463-6. [PMID: 18304507 DOI: 10.1016/j.amjsurg.2007.04.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 04/05/2007] [Accepted: 04/09/2007] [Indexed: 01/08/2023]
Abstract
BACKGROUND Whether all patients undergoing cholecystectomy following an episode of biliary pancreatitis require direct common bile duct evaluation is controversial. We hypothesized such evaluation can be omitted safely among select patients at low risk for choledocholithiasis. METHODS One hundred forty-eight patients undergoing cholecystectomy for biliary pancreatitis (January 1995-December 2005) met the following inclusion criteria: (1) no preoperative endoscopic retrograde cholangiography (ERC) or endoscopic retrograde cholangiopancreatography (ERCP); (2) normal or decreasing liver function tests (LFTs) preoperatively; and (3) no ductal dilation on non-invasive preoperative imaging. Group I had intraoperative cholangiography (IOC, n = 27); group II did not (n = 121). RESULTS No differences between groups I and II were evident in postoperative retained-stone related events: recurrent pancreatitis (11% vs 8%, P = .7), cholangitis (0% in both groups), and asymptomatic LFT elevation (0% vs 3%, P > .99). CONCLUSIONS Direct ductal evaluation can be omitted safely in select patients undergoing cholecystectomy for biliary pancreatitis who are at low risk for choledocholithiasis.
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Affiliation(s)
- Kaori Ito
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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Kim HC, Yang DM, Jin W, Ryu CW, Ryu JK, Park SI, Park SJ, Shin HC, Kim IY. Multiplanar reformations and minimum intensity projections using multi-detector row CT for assessing anomalies and disorders of the pancreaticobiliary tree. World J Gastroenterol 2007; 13:4177-84. [PMID: 17696245 PMCID: PMC4250615 DOI: 10.3748/wjg.v13.i31.4177] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
CT scan is regarded as the imaging modality of choice in patients with pancreaticobiliary ductal abnormalities. However, the axial orientation of the CT images provides only limited anatomical view of pancreaticobiliary ductal abnormalities. The technological advances of multi-detector row CT and three-dimensional image processing in workstations allows rapid image acquisition and a short postprocessing time. In particular, multiplanar reformations (MPR) and minimum intensity projections (MinIP) offer rapid and accurate images of the anatomy and abnormalities of the pancreaticobiliary tree. Moreover, MPR and MinIP help determine the relationship between the pancreaticobiliary ductal anatomy and the surrounding structures. This pictorial review illustrates the wide spectrum of images obtained by the MPR and MinIP of the anomalies and disorders of the pancreaticobiliary tree.
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Affiliation(s)
- Hyun Cheol Kim
- Department of Radiology, East-West Neo Medical Center, Kyung-Hee University, 149 Sangil-dong, Gangdong-gu, Seoul 134-727, Republic of Korea.
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De Waele E, Op de Beeck B, De Waele B, Delvaux G. Magnetic resonance cholangiopancreatography in the preoperative assessment of patients with biliary pancreatitis. Pancreatology 2007; 7:347-51. [PMID: 17703081 DOI: 10.1159/000107269] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 04/23/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND The ultimate treatment of acute biliary pancreatitis (ABP) is undoubtedly laparoscopic cholecystectomy, but controversy remains about the optimal imaging method in the preoperative assessment of these patients. In this study, we evaluated the usefulness of magnetic resonance cholangiopancreatography (MRCP) in detecting common bile duct (CBD) stones and associated pathologies in patients with ABP. At the same time, we tried to determine the natural transit time of gallstones from gallbladder to duodenum in ABP. METHODS Between February 1999 and October 2006 a prospective observational study was conducted and 104 consecutive patients with ABP were recruited. MRCP findings were correlated with subsequent endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, intraoperative cholangiography or clinical follow-up. RESULTS MRCP correctly predicted the presence of CBD stones in 19 out of 104 patients, and there were two false-positive and four false-negative results. The ability of MRCP to detect CBD stones was: positive predictive value 90.5%, negative predictive value 95.2%, sensitivity 82.6%, specificity 97.5% and overall accuracy 94.2%. MRCP performed within 48 h after admission showed CBD stones in 28.6% of the patients decreasing to 8.0% after 1 week. MRCP disclosed cholecystitis in 25 patients, anatomical variants of the cystic duct in 10 patients and a wide variety of other abnormalities of the upper abdominal cavity. CONCLUSION MRCP is highly accurate in the preoperative detection of CBD stones and other biliopancreatic pathologies in patients with gallstone pancreatitis.
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Affiliation(s)
- E De Waele
- Department of Surgery, VUB University Hospital, Brussels, Belgium.
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Bertolín-Bernades R, Sabater-Ortí L, Calvete-Chornet J, Camps-Vilata B, Cassinello-Fernández N, Oviedo-Bravo M, Monco PIG, Cánovas-de Lucas R, Lledó-Matoses S. Mild acute biliary pancreatitis vs cholelithiasis: are there differences in the rate of choledocholithiasis? J Gastrointest Surg 2007; 11:875-9. [PMID: 17458591 DOI: 10.1007/s11605-007-0148-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The rate of choledocholithiasis at the time of elective surgery after mild acute biliary pancreatitis is still unclear because it decreases rapidly after the onset. The aims of this study are as follows: (1) To investigate whether the incidence of choledocholithiasis in mild biliary pancreatitis is higher than in patients with symptomatic cholelithiasis. (2) To evaluate the usefulness of intraoperative cholangiography in the diagnosis of unsuspected choledocholithiasis in mild pancreatitis. Prospective study including 130 patients undergoing laparoscopic surgery and classified into two groups: mild biliary pancreatitis (n = 44) and symptomatic cholelithiasis (n = 86). Choledocholithiasis was evaluated by endoscopic cholangiopancreatography, magnetic resonance, and intraoperative cholangiography. Preoperatively, choledocholithiasis was identified in five patients with symptomatic cholelithiasis and two with biliary pancreatitis (5.81 vs 4.54%; p = 0.472). In 117 cases (90%), intraoperative cholangiography was successfully performed, identifying unsuspected choledocholithiasis in five patients of the colelithiasis group and in three in the group of pancreatitis (5.81 vs 6.81%; p = 0.492). The total number of patients with choledocholithiasis in the whole series was 15 (11.5%); 11.6% in colelithiasis group vs 11.4% in biliary pancreatitis group; p = 0.605. The rate of choledocholithiasis was not significantly different between the groups of patients with mild acute biliary pancreatitis and symptomatic cholelithiasis. Intraoperative cholangiography identified unsuspected choledocholithiasis in 6.81% of patients with mild acute biliary pancreatitis.
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Affiliation(s)
- Rosa Bertolín-Bernades
- Department of Surgery, Hospital Clinico, University of Valencia, Avda Blasco Ibañez, no. 17, 46010 Valencia, Spain
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Alexakis N, Lombard M, Raraty M, Ghaneh P, Smart HL, Gilmore I, Evans J, Hughes M, Garvey C, Sutton R, Neoptolemos JP. When is pancreatitis considered to be of biliary origin and what are the implications for management? Pancreatology 2007; 7:131-41. [PMID: 17592225 DOI: 10.1159/000104238] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm.
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Affiliation(s)
- N Alexakis
- Division of Surgery and Oncology, University of Liverpool, Royal Liverpool University Hospital, Liverpool, UK
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Abstract
Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to devastating acute illness with a significant risk of death. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.
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Affiliation(s)
- Paul R Tarnasky
- Digestive Health Associates of Texas, Methodist Dallas Medical Center, 221 West Colorado Boulevard, Suite #630, Pavilion II, Dallas, TX 75208, USA.
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