Dilek Oguz

Endoscopic Management of Biliary Obstruction Caused by Cavernous Transformation of the Portal Vein

BACKGROUND Symptomatic biliary obstruction caused by cavernous transformation of the portal vein is an extremely rare disorder for which there is no consensus as to optimal treatment. The results of endoscopic treatments in a small group of patients is reviewed. METHODS A total of 10 patients (5 men, 5 women; mean age 36.1 years, range 17-48 years) with severe biliary strictures were treated between 1995 and 2001. Biliary sphincterotomy was performed in all patients. Four patients also underwent balloon dilation, nasobiliary drainage, and stone or sludge extraction by using a balloon. All patients had stent insertion. OBSERVATIONS The mean duration of therapy was 3.3 years (range 1-7 years). There was no complication directly related to the endoscopic procedures except for hemobilia that occurred in one patient during stent removal. Cholangitis developed in 5 patients during the therapy period and was treated endoscopically. In 4 patients, significant improvement in the biliary stricture was observed and stents were removed in 3. These patients were followed without stent insertion for one year. CONCLUSIONS Endoscopic management of biliary stricture caused by cavernous transformation of the portal vein appears to be effective and safe.

Chronic pancreatitis and aortic pseudoaneurysm in Behçet's disease.

Behçets disease is a chronic, recurrent, systemic disease characterized by orogenital ulcers and oculocutaneous inflammatory lesions. Cardiovascular, pulmonary, neurological, articular, and GI involvement are common features, but pancreatic involvement is very rare. We present a case of Behçets disease with both chronic pancreatitis and abdominal aorta pseudoaneurysm.

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

BackgroundAnomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.MethodsThe data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.ResultsA total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).ConclusionThe opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.

Accuracy of endoscopic ultrasound-guided fine needle aspiration cytology on the differentiation of malignant and benign pancreatic cystic lesions: a single-center experience.

The aim was to compare the use of endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) in cytology and the biochemical analysis of cyst fluid, together with the size of the lesion in the differentiation between benign and malignant pancreatic cystic lesions.

Endoscopic Therapy of Hepatic Hydatid Cyst Disease in Preoperative and Postoperative Settings

The most common and serious complication of hepatic hydatid cyst disease is the communication between the cyst and the biliary tree. The diagnosis and treatment of this condition poses various difficulties. Data from patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for hydatid cysts communicating with the bile ducts either in the preoperative or postoperative setting over a 2-year period have been analyzed. In the preoperative group (n=41), jaundice (n=18), biliary colic (n=11), and cholangitis (n=10) were the most common presentations. On the other hand, the most common indication for ERCP in the postoperative group (n=69) was biliocutaneous leaks (n=60) and cholangitis (n=9). All but 2 patients in the preoperative group were treated by endoscopic sphincterotomy and/or extraction of hydatid cyst remnants followed by the placement of nasobiliary drainage catheter for the patients who had filling defects on cholangiogram. Subsequently, these patients were referred for surgery. ERCP was a definitive treatment for the remaining 2 patients. Endotherapy was successful for the patients who developed leak or had cyst remnants following surgery, whereas long-term biliary stenting was required for those who developed bile duct stenosis. There was no ERCP-associated complication, except mild pancreatitis in a single patient and self-limited hemorrhage in 2 patients. ERCP is an efficacious and safe method for the diagnosis and management of biliary complications associated with hydatid cyst disease.

Comparison of endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and fecal elastase 1 in chronic pancreatitis and clinical correlation.

Objectives: In this study, we prospectively compared the use of endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), and fecal elastase 1 in patients with chronic pancreatitis and searched for correlation with symptoms, clinical findings, and elastase 1 levels. Methods: Twenty-four consecutive patients (19 were male, and 5 were female) with chronic pancreatitis who had already undergone ERCP within the last 2 years and 19 healthy control subjects (10 were male, and 9 were female) are studied prospectively. Clinical and laboratory parameters of the patients were recorded, and all underwent EUS and fecal elastase 1 testing. Fecal elastase 1 was measured in healthy control subjects. Results: The ERCP and EUS severity scores were 1 in 0 to 2 patients, 2 in 6 to 8 patients, and 3 in 18 to 14 patients. Sensitivity and specificity of fecal elastase for chronic pancreatitis were 75% and 100%, respectively. There was a negative correlation between disease duration and fecal elastase 1 levels. Patients with dyspepsia or those who use pancreatic enzyme preparations had significantly lower fecal elastase 1 levels than others. Conclusions: Endoscopic retrograde cholangiopancreatography and EUS are nearly equal in staging chronic pancreatitis. Fecal elastase 1 correlates well with these tests. Fecal elastase 1 also correlates well with some clinical symptoms such as dyspepsia and disease history.

Endosonographic evaluation of patients with suspected extraluminal compression or subepithelial lesions during upper gastrointestinal endoscopy

Background The aim of this study was to evaluate the endosonographic ultrasound (EUS) findings of patients with suspected extraluminal compression or subepithelial intramural lesions observed during upper gastrointestinal endoscopy. Methods EUS findings were grouped as follows; compression by an extramural pathologic lesion, compression by an adjacent vascular structure, compression by adjacent organs, subepithelial intramural lesion, and normal EUS. Results The data of 211 patients referred to the EUS unit between February 2004 and January 2010 for further evaluation of suspected extraluminal compression or subepithelial intramural lesions after upper gastrointestinal endoscopy were retrospectively analyzed. Mean age of the patients was 51.0±15.2 years, 124 (58.9%) of which were female. EUS examination was normal in 48 (22.7%) patients. EUS confirmed the presence of a pathological finding in the esophagus in 38 (92.6%) out of 41 patients when compared with abnormal findings in 122 (73.4%) of 166 patients who were evaluated for suspected lesions of the stomach (P=0.009). Suspected extraluminal compression of the esophagus (n=41) was due to a vascular structure in 17 (41.4% ) patients, an adjacent organ in four (9.7%) patients, an extramural pathological lesion in two (4.9%) patients, and a subepithelial intramural lesions in 15 (36.6%) patients, whereas in three patients (7.4%) EUS findings were normal. Of the 166 patients referred for evaluation of gastric lesions EUS findings were normal in 44 (26.5%) patients, whereas compression due to an adjacent organ was observed in 66 (39.7%) patients followed by compression by an adjacent vascular structure in 34 (20.4%) patients. An extramural pathologic lesion was discovered in 14 (8.6%) patients, whereas suspected compression was due to a subepithelial intramural lesion in eight (4.8%) patients. Conclusion Accurate diagnosis of suspected extraluminal compression or subepithelial intramural lesions, particularly in the stomach, requires meticulous evaluation. EUS provides an invasive but effective option. In one-third of cases, suspected extraluminal compression of the esophagus is actually due to a subepithelial intramural lesion.

The long-term effects of lamivudine treatment in patients with HBeAg-negative liver cirrhosis

IntroductionIn hepatitis B virus (HBV)-related liver cirrhosis, patients with HBV replication show a higher mortality rate than those without. We aimed to investigate the long-term effects of lamivudine on HBV DNA suppression, Child-Pugh score, and survival in patients with hepatitis Be antigen (HBeAg)-negative liver cirrhosis.MethodsSixty-eight patients (51 male, 17 female) diagnosed with HBV-positive liver cirrhosis, who were monitored by the hepatology and liver transplantation outpatient clinics of our hospital between June 1999 and May 2007, were included in the study. Lamivudine (100 mg/day) was administered orally. Follow-up visits were scheduled monthly during the first 3 months, and every 3 months thereafter. Complete blood count, haemostasis, biochemistry (aspartate aminotransferase [AST], alanine aminotransferase [ALT], amylase, urea, creatinine, total bilirubin, direct bilirubin, total protein, albumin), and alpha-foetoprotein were recorded every 3 months. HBV DNA levels, abdominal ultrasound and the Child-Pugh score were evaluated every 6 months.ResultsSixty-eight patients (mean age, 52.05±12.6 years) were monitored for 49.51±18.51 months. Basal ALT, HBV DNA levels and Child-Pugh scores were 103.9±73.9 IU/ml, 4133±121,94 IU/ml, and 7.6±2.4, respectively. The ALT normalisation was 59.7% during the first year, 68.2% during the second year and 44.4% during the fifth year. There was a significant decrease in Child-Pugh scores in the first 3 follow-up years when compared with the baseline score (P<0.05). During the treatment, HBV DNA positivity and YMDD mutations were determined in 20 of 68 (29.4%) patients at 46±17.9 months. Nine patients (13.2%) developed hepatocellular carcinoma at 44.8±21.5 months. Thirteen patients (19.1%) died during the treatment due to liver failure or variceal bleeding.ConclusionLamivudine is beneficial in patients with HBeAg-negative liver cirrhosis in terms of improvement in liver function and enhancement of survival and quality of life. An HBV DNA suppressive effect and improvement in Child-Pugh score were seen especially in the first years. It is important to be aware of YMDD mutation early, as addition of new antivirals is necessary to overcome unwanted results of the mutation.

Demonstration of retraction of the main papilla toward the biliary system in patients with primary sclerosing cholangitis with magnetic resonance cholangiopancreatography

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts, which leads to the formation of multifocal bile duct strictures. In a previous study we found that the main papilla was retracted toward the biliary system in 7 of 10 patients (70%) with PSC. Retraction of the papilla was defined as the embedding of the papilla into the duodenum wall and peripapillary duodenal convergence (i.e. tent-like appearance). It was suggested by our team that the presence of the main papillary retraction may be a useful sign in the diagnosis of PSC.Herein, two patients in whom this finding could be detected on magnetic resonance cholangiopancreatography (MRCP) are presented. Patient 1: A 43-year-old man with Crohn’s disease was diagnosed as having PSC in January 1998 and underwent endoscopic sphincterotomy. In May 2004, endoscopy showed retraction of the main papilla. MRCP was performed in May 2008 in order to search for the presence of dominant stricture or cholangiocarcinoma because of increasing pruritus and liver enzyme levels. The papilla was seen to be retracted toward the biliary system (Fig. 1), which was confirmed on endoscopy. Patient 2: A 47-year-old man with a history of asymptomatic increase in liver enzymes underwent MRCP in October 2006. At that time, a diagnosis of PSC was made, but there was no retraction of the main papilla. Endoscopic cholangiography was not performed because the patient was asymptomatic. In May 2009, the patient presented with itching and cholangitis. MRCP at this time showed retraction of the main papilla toward the biliary system (Fig. 2). The capacity of MRCP to show retraction of the main papilla provides a valuable alternative to endoscopy. The air that is introduced into the gastrointestinal lumen during endoscopy inflates the duodenum. As a result, the retracted position of the main papilla becomes less apparent. Another benefit of MRCP is that it avoids the possibility of the papilla being pushed artificially into a retracted position by the endoscopic catheter. In our opinion, retraction of the main papilla in patients with PSC can be included among the criteria for diagnosing this disease via MRCP.

A Rare Cause of Upper Gastrointestinal Bleeding: Stromal Tumor of Duodenum Masquerading as Papilla Vateri

A Rare Cause of Upper Gastrointestinal Bleeding: Stromal Tumor of Duodenum Masquerading as Papilla Vateri