Charles F. Gholson

Endoscopic diagnosis and management of biliary complications following orthotopic liver transplantation

Nonoperative management of biliary complications (BC) with endoscopic retrograde cholangiopancreatography (ERCP) is a natural sequel to the emergence of choledochocholedochostomy as the preferred biliary reconstruction for orthotopic liver transplantation (OLT). Overall, therapeutic ERCPs efficacy for posttransplant BC is difficult to assess because most published data are retrospective, anecdotal, or in abstract form, and there are no prospective, randomized studies. Thus, endoscopic management of posttransplant BC must be individualized. While T-tube-related late bile leaks and ductal calculi are amenable to endoscopic therapy, its efficacy for strictures is more difficult to define. Refined surgical technique has prevented many unifocal anastomotic lesions, while multifocal strictures (for which endoscopic therapeutic experience is minimal) are increasingly prevalent. Whether endoscopic sphincterotomy is appropriate for posttransplant sphincter of Oddi dysfunction is controversial, because the disorder may be transient and the risk significant. Multicenter, prospective studies are needed to determine more accurately the optimal role of endoscopic therapy after OLT.

Needle Knife Papillotomy in a University Referral Practice: Safety and Efficacy of a Modified Technique

To study the utility of needle knife papillotomy (NKP), we retrospectively reviewed 575 consecutive endoscopic retrograde cholangiopancreatography (ERCP) procedures performed over a 3.5-year period. Seventy patients (12.2%) underwent NKP utilizing a shallow ampullary mucosal incision followed by probing with a taper-tipped cannula. Usually a prelude to anticipated therapeutic intervention, NKP was also performed purely for diagnosis in 15 patients (21.4%). The incised ampulla was normal-sized in the majority (53 of 70, 75.7%), and ductal dilatation was present in 49 of 70 cases (70%). NKP was performed de novo in 63 patients, one of whom had Billroth II anatomy, and stent-guided NKP was performed in seven patients (10%), two of whom had Billroth II anatomy. Biliary access was immediate in 68 patients (97.1%) and successful 24 h later in two cases. The NKP incision was completed with a traction sphincterotome in 45 patients (64.3%). Complications occurred after NKP in five patients (7.1%), compared with 11 complications (4.2%) among a concurrent 261 patients who underwent standard ES without NKP. All complications following NKP were selflimited, including pancreatitis (n = 2) and bleeding (n = 2). Our experience indicates that NKP is versatile, effective, and safe with broad applicability in an academic referral practice.

Delayed hemorrhage following endoscopic retrograde sphincterotomy for choledocholithiasis

To define the clinical significance of delayed postsphincterotomy hemorrhage, we reviewed 476 consecutive ERCP procedures performed over a three-year period. Of 250 patients who underwent endoscopic sphincterotomy (ES), five (2%) developed postprocedure hemorrhage, two of whom had immediate, self-limited bleeding that resolved after endoscopic injection of epinephrine and did not require transfusion. The other three had delayed hemorrhage characterized by: onset 20–48 hr after the procedure, melena without hematemesis as the index clinical manifestation of bleeding, and atraumatic balloon extraction of common duct stones. Transfusion of 2–6 units of packed erythrocytes was necessary in each and one patient required surgical hemostasis. Delayed hemorrhage following ERS is an important, frequently severe complication to remember when contemplating performing ERS as an outpatient procedure.

Choledocholithiasis in patients with normal serum liver enzymes

Retrospective chart review of 330 patients undergoing ERCP over a two-year period yielded five patients with choledocholithiasis whose serum liver enzyme and total bilirubin levels were repeatedly normal. All were female, three were elderly, and the gallbladder wasin situ in three of the five, one of whom had a large gallbladder remnant. In four patients, the common bile duct was dilated (>10 mm), whereas none had intrahepatic duct dilatation. Four patients had a prominent ampulla, and stone size varied widely. Each patient was managed with endoscopic sphincterotomy and stone extraction followed by cholecystectomy for the four patients with the gallbladder or its remnantin situ. This small series proves that common duct stones may exist in patients with repeatedly normal serum liver enzyme and total bilirubin levels. We hypothesize that marked dilatation of the common bile duct or gallbladder may serve as a pressure sump and blunt liver enzyme elevation. Normal liver enzymes should not dissuade one from performing cholangiography in patients with suspected choledocholithiasis.

Recent Advances in the Management of Gallstones

Demands for less invasive, more cost-effective therapy have revolutionized the management of gallstones over the past 10 years. There are no reliable methods of permanently reversing the pathophysiologic defects that cause gallstones. Open cholecystectomy (OC), the gold standard for managing symptomatic cholelithiasis, has been largely replaced by laparoscopic cholecystectomy (LC), which has the advantages of a minimal hospital stay and quicker return to work. Other adjunctive therapies, limited in applicability to selected patients, include oral bile acid therapy (BAT), dissolutional agents, and extracorporeal shock wave lithotripsy. Choledocholithiasis (CDL), formerly managed exclusively with surgical common duct exploration, is increasingly treated with therapeutic biliary endoscopy. Methods of laparoscopic common bile duct exploration are being developed. Optimal algorithms for applying these techniques to patients undergoing LC are evolving. In a sense, the solution to all, or certainly most, gallstones now can be seen through a scope.

Diagnostic considerations in evaluation of patients presenting with melena and nondiagnostic esophagogastroduodenoscopy

Proper evaluation of patients with melena and nondiagnostic esophagogastroduodenoscopy is comparatively undefined. We sought to determine the percentage of patients with melena and nondiagnostic upper endoscopy and assess the yield of further evaluation. Of 209 patients presenting with melena, 180 underwent esophagogastroduodenoscopy as the initial study, which was nondiagnostic in 43 cases (24%). Further evaluation was pursued in 30. A presumed source of melena was found in 11 patients (37%), identified by colonoscopy in seven, bleeding scan in three, and barium enema plus flexible sigmoidoscopy in one. Nearly all such defined cases originated from the right colon. Small bowel contrast studies, flexible sigmoidoscopy or barium enema alone, and angiography failed to reveal a source. Our findings suggest that many (24%) patients presenting with melena will have nondiagnostic upper endoscopy; further evaluation reveals a potential source in 37% of this group, with the right colon being the most likely location of pathology; and colonoscopy is the test of choice in this cohort.

Endoscopic Retrograde Sphincterotomy in Swine

Endoscopic retrograde sphincterotomy was performed on four sedated pigs, ages 3–4 months, using a standard human duodenoscope and papillotome. Sphincterotomies, 1 cm in length, were well-tolerated, and all animals recovered promptly, spontaneously regained gastrointestinal function, and gained weight. The first three animals were sacrificed after one week, and autopsy revealed no complications. The fourth animal was sacrificed immediately following the procedure, and no evidence of perforation was found. These observations demonstrate that the pig is a valid experimental model for endoscopic sphincterotomy. Its use in training is limited by technical and anatomic differences from humans. Potential uses of this technique in research are discussed.

Suspected biliary complications after laparoscopic and open cholecystectomy leading to endoscopic cholangiography : a retrospective comparison

To study how suspected postoperative biliarycomplications are influenced by surgical technique, wecompared clinical profiles of 63 patients referred forERCP after open (OC) and laparoscopic cholecystectomy (LC) over a four-year period. ERCP was notperformed for postoperative pain alone and only six(9.5%) studies were normal. Referrals after LC wereyounger (mean 39.1 vs 53.6 years, P < 0.001) and ERCP was requested earlier (mean 71.6 vs 2360 days,P < 0.001) in the postoperative course.Choledocholithiasis (CDL) alone, the most commonfinding, was successfully managed with a single ERCP in97.2% of cases. CDL after LC occurred in youngerpatients (35.5 vs 58.9 years, P < 0.01) who presentedearlier (mean 98.6 days vs 5.1 years, P < 0.01),without biliary ductal dilatation (P < 0.01).Although CDL after LC was associated with higher ALT andbilirubin levels than after OC, the difference was notstatistically significant. Cystic duct leaks (LC: sixpatients, OC: four patients) were typically associated with CDL after OC and 90% resolved withendoscopic therapy. Biliary ligation (four cases) wasmanaged successfully with choledochojejunostomy. Weconclude that findings at ERCP for suspected biliaryobstruction or injury after OC or LC are similar andusually can be endoscopically managed. After LC,referrals currently are younger, present much earlier,and retained stones are less likely to be associatedwith ductal dilatation than after OC.

Essentials of clinical hepatology

Essentials of hepatic function practical hepatic anatomy and physiology evaluation of patients with liver disease the history and physical examination in hepatologic practice the use of liver tests for the diagnosis and management of liver disease and jaundice liver biopsy - clinical utility technique and limitations diseases of the liver and biliary tree acute viral hepatitis chronic non-alcoholic liver disease alcoholic liver disease.

LIVER TRANSPLANTATION : WHEN IS IT INDICATED AND WHAT CAN BE EXPECTED AFTERWARDS ?

Preview How many months of documented abstinence are required before a patient with alcoholic cirrhosis can be considered for liver transplantation? What is the role of liver transplantation as treatment for primary hepatocellular cancer? What are the possible causes of elevated liver enzyme levels following transplantation? Which patients with neurologic injury are potential organ donors? The authors answer these and other questions primary care physicians may have about this lifesaving procedure.