Deepak K. Agarwal

Biliary microlithiasis in patients with idiopathic acute pancreatitis and unexplained biliary pain: Response to therapy

Background and Aims:  Microlithiasis has been suspected to cause acute pancreatitis and biliary pain. We studied the frequency of microlithiasis and response to treatment in recurrent idiopathic acute pancreatitis (RIAP) and unexplained biliary pain.

Bile lithogenicity and gallbladder emptying in patients with microlithiasis: Effect of bile acid therapy

BACKGROUND & AIMS Biliary cholesterol supersaturation, rapid nucleation of cholesterol, and altered gallbladder motility are prerequisite for gallstone formation. However, the pathogenesis of microlithiasis is not clear. The aim of this study was to determine the abnormalities of gallbladder emptying and bile composition in patients with microlithiasis. METHODS Nucleation time, cholesterol saturation index (CSI), and gallbladder emptying were studied in patients with microlithiasis (n = 10), patients with gallstones (n = 10), and healthy volunteers (n = 10). Bile analysis was repeated in 6 patients with microlithiasis treated with ursodeoxycholic acid (UDCA) for 8 weeks. RESULTS Nucleation time was shorter in patients with microlithiasis and those with gallstones than in healthy volunteers (P < 0.0001). Patients with microlithiasis had longer nucleation time than those with gallstones (P < 0.001). There was no difference in cholesterol levels and CSI in gallstone and microlithiasis patients. However, healthy volunteers had lower cholesterol levels (P < 0.01) and CSI (P < 0.01). Patients with microlithiasis had prolongation of nucleation time (P < 0.001) and lowering of CSI (P < 0.001) after UDCA therapy. Gallbladder ejection fraction was higher in microlithiasis patients than in gallstone patients (P < 0.01) but lower than in healthy volunteers (P < 0.01). CONCLUSIONS Patients with microlithiasis have longer nucleation time and better gallbladder emptying than patients with gallstones. Bile abnormalities can be successfully corrected with UDCA therapy in patients with microlithiasis.

Percutaneous catheter drainage of amoebic liver abscess

Fifteen patients with amoebic liver abscesses underwent percutaneous catheter drainage under ultrasonographic guidance. Thirteen patients had solitary abscesses (right lobe 12, left lobe 1), two had associated subdiaphragmatic collections, while two patients had multiple abscesses. The indications for the drainage included lack of response to medical therapy: imminent rupture in five cases; ruptured liver abscesses in three; enlarging abscesses after hospitalization in three; persistent symptoms in two; and large left lobe abscesses in two. The volume of the abscesses before drainage was 102-1008 ml (mean 432 ml). Pigtail catheters (8 F) were used in nine of the patients and 12 F sump catheters in six. When multiple abscesses and associated subdiaphragmatic collection were present, each was drained separately. The catheters were removed (mean 7 days, range 3-20 days) when patients became apyrexial, catheter drainage was less than 10 ml in 24 h and cavitogram showed a negligible cavity (mean residual volume 5.5 ml, range 3-15 ml). Complications included minor blood loss through the catheter for 12 h in one patient and reappearance of the abscess in another requiring further drainage. Our experience suggests that catheter drainage of amoebic liver abscesses in selected cases is safe and effective, and results in prompt and early resolution of the abscess cavity with restoration of normal parenchyma.

Endoscopic management of acute calculous cholangitis.

Acute cholangitis is associated with significant morbidity and mortality. Endoscopic drainage procedures have been shown to be a safe and effective mode of treatment in acute cholangitis. As there is paucity of large series on endoscopic management of acute cholangitis, a study was performed to evaluate safety and efficiency of endoscopic biliary decompression in acute cholangitis. The study included 89 consecutive patients (mean age 55 ± 15 years; range 35–70 years; 50 males) with acute cholangitis requiring biliary drainage. Main presenting features were upper abdominal pain (84%), fever with chills (90%) and jaundice (74%). Altered sensorium, hypotension, features of peritonitis and acute renal failure were present in 15, 11, 18 and 5%, respectively. Endoscopic procedures performed were endoscopic sphincterotomy (ES) with stone extraction (n= 40); ES with endoscopic nasobiliary drainage (ENBD; n= 30); ENBD without ES (n= 8); and ES with stent placement (n= 11). Of the 89 patients, 85 (95%) responded within 48–72 h. Endoscopic common duct clearance could be achieved in 58 of 78 (74%) patients, whereas in 11 patients undergoing stent placement, stone extraction was not attempted. Complications included post‐sphincterotomy bleed (n= 2), retroduodenal perforation (n= 1) and acute pancreatitis (n= 1) with an overall complication rate of 4.4%. All the complications were seen in patients undergoing ES with stone extraction. Mortality was 3.3%. In conclusion, endoscopic biliary drainage is a safe and effective mode of treatment for acute cholangitis. Endoscopic nasobiliary drainage or stent placement is safer than ES in acute cholangitis as an initial step.

Percutaneous catheter drainage of amebic liver abscesses with and with out intrahepatic biliary communication: a comparative study

Influence of communication with the intrahepatic biliary system on the clinical picture of amebic liver abscesses in 33 consecutive patients resistant to medical therapy, and their response to percutaneous catheter drainage was evaluated. Abscess-biliary communication was found in 27% of the sample. Patients with abscesses communicating with the biliary tree presented more frequently with jaundice (67% vs. 0%, P < 0.005), with a longer duration of illness (median 20 vs. 12 days, P < 0.001), had larger lesions (median 600 vs. 320 ml, P < 0.001) and required catheter drainage for longer periods (median 17 vs. 6.5 days, P < 0.000001). However the presence of a biliary communication did not materially affect the cure rate with catheter drainage (89% vs 100%, P > or = 0.05). In conclusion, an abscess-biliary communication is not uncommon in refractory amebic liver abscesses, and can be clinically detected by the presence of jaundice. Though a prolonged period of drainage may be necessary in the presence of this complication, catheter drainage can be expected to result in cure.

Endoscopic management of postoperative bile leak

Significant bile leak is an uncommon but serious complication of biliary tract surgery. Of twenty‐five patients presenting with postoperative bile leak, 11 had complete tie‐off of common bile duct and required surgery, while the remaining 14 had injury without complete obstruction and could be managed by endoscopic methods. Of these 14 cases, bile leak occurred from the cystic duct in 11 patients and from the common hepatic duct, right hepatic duct and left hepatic duct in one patient each. Endoscopic procedures performed included sphincterotomy alone (four patients), sphincterotomy and stent placement (seven patients) and sphincterotomy followed by nasobiliary catheter drainage (three patients). There was no technical failure and bile leak was stopped in all patients. One patient died of haemobilia 5 days after stent placement. When technically feasible, postoperative bile leak can be managed safely and effectively by endoscopic methods, obviating the need for surgical reexploration.

Complex ruptured amebic liver abscesses: the role of percutaneous catheter drainage

The failure of medical therapy for amebic liver abscess may be followed by its perforation, a complication associated with high mortality. We assessed the role of percutaneous catheter drainage in management of the sequelae of ruptured amebic abscesses in 13 critically ill patients; 22 intrahepatic lesions, three of which were multiloculated, were drained. Catheters were also placed in 17 extrahepatic collections: pleural space (n = 5), subphrenic (n = 7), perihepatic/subhepatic (n = 3), greater sac of peritoneum (n = 2). No attempt at percutaneous drainage failed. Prompt resolution of clinical features following drainage was a uniform feature. Successful resolution of the abscesses occurred within 20 days in 11 patients. In the remaining two, catheters needed to be retained in situ for 35 and 50 days. The mean hospital stay was 15 days (range 10-20 days). 100% patient survival was achieved, without a single morbid episode. Our results suggest that patients with ruptured amebic abscesses can be effectively and safely managed by percutaneous catheter drainage irrespective of the extent of extrahepatic contamination.

Biliary stenting for management of common bile duct stones

Large and multiple common bile duct stones may defy extraction despite an adequate endoscopic papillotomy. We treated 65 patients with symptomatic bile duct stones with endoscopic stents after failed attempts at stone extraction. Of the 65 patients, bile duct stones were extracted in eight at a second attempt, 29 underwent elective surgery and 28 patients were followed with the stent in situ for 21–52 months (median 42 months). During follow up, two patients had recurrent pain and two required surgery. The remaining 24 patients remained asymptomatic. Biliary stenting is a safe and effective mode of treatment for common bile duct stones in patients who have failed stone extraction after endoscopic papillotomy.

Biliary ascariasis complicating endoscopic sphincterotomy for choledocholithiasis in India

Endoscopic sphincterotomy is the treatment of choice for patients with choledocholithiasis. Biliary ascariasis has been reported from many parts of the world but is common in Kashmir, India. We report five cases of biliary ascariasis of which four were the result of post‐endoscopic sphincterotomy for choledocholithiasis. Therefore, biliary ascariasis is not an uncommon complication of endoscopic sphincterotomy.

'Latent' portal hypertension in benign biliary obstruction.

A prospective study was undertaken to evaluate the changes in portal venous pressure in patients with benign biliary obstruction (BBO) but without overt clinical, endoscopic or radiological evidence of portal hypertension. Portal venous pressure was measured at laparotomy in 20 patients (10 each with either benign biliary stricture or choledocholithiasis) before and after biliary decompression. Pressure was found to be on the high side in seven patients (>25 cm of saline in three patients and > 30 cm of saline in four). The mean fall of pressure was 3.4 cm of saline after biliary decompression. No correlation could, however, be found between portal venous pressure and duration of biliary obstruction, serum bilirubin or bile duct pressure. Liver histology showed mild to moderate cholestatic changes but maintained portal architecture in all. Benign biliary obstruction may therefore, lead to elevation of portal pressure, even though the patient may not necessarily have any clinical, endoscopic or radiological manifestations of portal hypertension. The pathogenesis of this ‘latent’ portal hypertension is probably multifactorial. If biliary obstruction is left untreated the development of overt portal hypertension may become a possibility in the future.