William B. Silverman

Nasobiliary tube management of postcholecystectomy bile leaks.

Background: Endobiliary stenting is the traditional form of endoprosthetic drainage for biliary leaks. Nasobiliary tubes offer the advantage of easy removal and interval tube cholangiograms to assess leak resolution. Aim: To determine the efficacy of nasobiliary tube drainage in patients with postcholecystectomy biliary leaks and provide our experience with management of biliary leak using nasobiliary drains. Materials and Methods: Retrospective study of 24 patients who were treated for postcholecystectomy biliary leaks in a tertiary referral center from 1998 to 2002. These patients were managed with either nasobiliary tube (NBT) alone or NBT + endoscopic sphincterotomy (ES). Results: Twenty-four patients (mean age, 57.5 years; 50% women) had postcholecystectomy leak noted on ERCP. Twenty patients were managed by NBT+ES and 4 patients had NBT placement alone. In the NBT+ES group, 2 patients pulled their NBT out, but 18 patients had complete leak resolution in 3 to 9 days. In the NBT group, all patients had complete leak resolution in 4 to 12 days. Using an intention-to-treat analysis, 22 of 24 (92%) patients were successfully treated with NBT treatment over 3 to 12 days. Conclusions: ERCP with NBT placement is an effective and safe treatment modality in the management of postcholecystectomy biliary leaks.

Case Report: Cholestatic Jaundice Induced by Ciprofloxacin

The patient was a 47-year-old white man who developed symptoms of nausea, vomiting, and diarrhea 4 ± 5 hr after eating a hamburger at a local resort. He presented with these symptoms to a nearby hospital that evening. Laboratory evaluation was remarkable for a white-cell count of 18 3 10/mm. Urinalysis showed 4 ± 5 white blood cells/per high power ® eld, trace leukocyte esterase, and no bacteria. Stool cultures performed at this time were later negative. The patient denied taking any over-the-counter medication at any time and had no history of drug allergies. Past medical history was unremarkable. The patient was hydrated with intravenous ̄ uids and discharged. The vomiting and diarrhea resolved over the next few days, but nausea and general malaise still persisted four days later. He, therefore, saw his local physician. Because of the occult pyuria noted at the time of the emergency department visit, he was treated with cipro ̄ oxacin 500 mg per os twice a day. After three doses of cipro ̄ oxacin, the patient noticed mild jaundice and pruritis. These symptoms increased and cipro ̄ oxacin was discontinued 24 hr later. Marked jaundice followed, and he saw his physician again three days later. At this time, physical exam and history were remarkable only for jaundice and fatigue. Total bilirubin (Tbili) was elevated to 10 mg/liter (normal 0.0 ± 0.3), with a direct bilirubin (Dbili) of 6.5 mg/liter (normal 0.0 ± 0.2). Alkaline phosphatase was elevated to 163 IU/liter (normal 40 ± 125), aspartate aminotransferase (AST) was 109 IU/liter (normal , 40), and alanine aminotransferase (ALT) was 308 IU/liter (normal , 40). Two weeks later his bilirubin continued to rise, and he was admitted to a local hospital. These results are summarized in Table 1. Serology for hepatitis A, B, and C was negative. Prothrombin time was prolonged 5 sec, then normalized with parenteral vitamin K. Ultrasound of the gallbladder was unremarkable. The patient was subsequently transferred to our institution because of concerns that he might be developing fulminant liver failure. Upon arrival, he complained of persistent pruritis and fatigue, but had no other symptoms. His vital signs were normal and physical exam revealed only marked jaundice. There was no hepatomegaly or splenomegaly. Abdominal ultrasound was normal. Abdominal CT scan revealed a single small gallbladder stone, no intraor extrahepatic ductal dilatation, and a normal liver. Serum tests for hepatitis B virus DNA polymerase chain reaction (PCR) and hepatitis C virus RNA reverse-transcriptase PCR were negative. Liver biopsy (Figure 1) revealed intact lobular architecture, with no evidence of in ̄ ammatory cell in® ltrates in the portal tracts. Lobules showed a mild to moderate intracellular and intracanalicular cholestasis. Hepatocytes showed regenerative activity, and there were scattered necrotic hepatocytes with foci of chronic in ̄ ammatory cells. Mild macroand microvesicular steatosis was present, but there was no eosinophilic in® ltrate and no evidence of ® brosis or cirrhosis. The patient’ s jaundice improved, and he was discharged after ® ve days. We followed him closely as an outpatient. His symptoms (mild fatigue, jaundice, pruritis) improved and his liver tests returned to normal over the next 12 weeks.

Outcome of ERCP in the Management of Duct-to-Duct Anastomotic Strictures in Orthotopic Liver Transplant

This study sought to determine the efficacy of endoscopic treatment of duct-to-duct anastomotic stricture in orthotopic liver transplant. A retrospective chart and database review was carried out using procedure and diagnosis codes during the period of 1997–2001. One hundred ninety-eight adult patients underwent orthotopic liver transplantation from 1997 to 2001. Fifteen patients (age 52±9 years; 60% women) with duct-to-duct anastomotic strictures were identified. They underwent a total of 53 endoscopic retrograde cholangiopancreatographies (ERCPs) and received different endoscopic treatments including biliary dilation, stent placement, and sphinctrerotomy. Thirteen of these patients (87%) had complete resolution of stricture. Of the remaining two patients, one had partial resolution of stricture and underwent long-term self-expanding metal stenting, while the other had no resolution after two ERCPs. We conclude that ERCP was effective in treating 87% of the duct-to-duct anastomotic strictures in this series.

Biliary Sphincter of Oddi Dysfunction Type I Versus Occult Biliary Microlithiasis in Post-cholecystectomy Patients: Are They Both Part of the Same Clinical Entity?

We speculate that biliary sphincter of Oddi dysfunction type I and symptomatic migrating biliary microlithiasis may be part of the same disease process. A retrospective analysis of prospectively collected data was carried out using procedure and diagnosis codes during the period of 1997–2006. Seventeen patients (age 51xa0±xa017; 94% women) with prior cholecystectomy, right upper quadrant/epigastric abdominal pain, elevated liver enzymes, dilated biliary ducts seen on ultrasound/CT scan were identified. The patients underwent ERCP with biliary endoscopic sphincterotomy. Nine (53%) had biliary microlithiasis and eight (47%) had biliary sphincter of Oddi dysfunction type I. They were followed for 2–108xa0weeks (median 9xa0weeks). 6/8 (75%) in biliary sphincter of Oddi dysfunction type I and 6/9 (67%) in biliary microlithiasis group had resolution of abdominal pain (Pxa0=xa01.00). We conclude that the clinical improvement with biliary sphincterotomy for biliary sphincter of Oddi dysfunction type I versus occult biliary microlithiasis was not significantly different.

Diagnostic and therapeutic approach to pancreatic cancer-associated gastroparesis: literature review and our experience.

Background Patients with unresectable pancreatic carcinoma often present with early satiety, nausea, and vomiting without evidence of mechanical obstruction, mucosal disease, or metabolic abnormality. This condition is well described in the literature and is thought to result from pancreatic cancer-associated gastroparesis (PCAG). No clinical guideline is available for diagnosing and managing this rare disease. Objective To propose an algorithm for diagnosing and managing patients with PCAG based on a literature review and our clinical experience. Methods A comprehensive review was conducted of literature on the subject from 1966 to 2005, and retrospective analysis was performed for patients with PCAG who presented to the University of Iowa Hospitals and Clinics (Iowa City, IA, USA) during the period 1998–2005. Results Literature on an optimal diagnostic and therapeutic approach to PCAG is lacking. There are only two small case series and one case report regarding management of PCAG. Extensive chart review only identified two patients who met the diagnostic criteria of PCAG. We propose performing routine upper GI series and esophagogastroduodenoscopy on all patients with pancreatic cancer who present with nausea and vomiting, to rule out obstruction and mucosal disease. If there is no obstruction or mucosal disease, we do not recommend further workup. Prokinetic agents are the first line therapy for PCAG. In refractory cases, percutaneous endoscopic gastrostomy with jejunal extension may be considered in selected patients who respond to nasojejunal decompression. Conclusions We propose a time-effective and useful strategy for diagnosing and managing patients with PCAG. We also define the diagnostic end-point for this difficult to manage condition.

Hybrid Classification of Sphincter of Oddi Dysfunction Based on Simplified Milwaukee Criteria

To date, when using the Milwaukee classification for sphincter of Oddi dysfunction (SOD), one cannot accurately classify patients with marginal elevations in laboratory tests; ie, <1.5 × the upper limit of normal (ULN). Since subsequent treatment may depend on how they are classified, we sought to determine whether these patients should be considered as type II or type III. Between January 1993 and October 1996, 113 consecutive patients (82 females and 31 males; ages 12–87 years) without prior sphincterotomy were referred to consider a diagnosis of SOD type II or III. SOD II patients had pancreaticobiliary-type pain and laboratory elevations >1.5 × ULN or dilated ducts, while SOD III patients had pain only. Hybrid patients had pain and marginal laboratory elevations <1.5 × ULN, with normal duct diameters. Drainage times, frequency, duration, and propagation were not assessed. Sphincter of Oddi manometry (SOM) was performed in each case, and the frequency of abnormal biliary and/or pancreatic basal sphincter pressure was compared, with respect to type II, III, and hybrid SOD. Successful SOM was obtained in 113/114 patients: Abnormal basal sphincter pressure was found in 65, 89, and 43% of type II, hybrid, and type III SOD, respectively. We found no statistical difference between type II and hybrid patients. In contrast, there was statistical difference between types II and III patients and between type III and hybrid patients. In conclusion, there was no significant difference in the frequency of elevated basal sphincter pressure in SOD type II versus hybrid, and thus they should be considered as one group.

Palliative Endoscopic Ultrasound-Guided Drainage of a Malignant Pancreatic Cyst Causing Gastric Outlet Obstruction

Background: Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has been well described but it is not an established therapy for malignant pancreatic cystic neoplasms. We report the first EUS-guided cystogastrostomy for the palliative treatment of a cystic pancreatic adenocarcinoma. Case Report: We describe a 70-year-old male with a nonresectable cystic pancreatic adenocarcinoma causing partial gastric outlet obstruction treated successfully with palliative EUS-guided cystogastrostomy stent placement. The diagnosis was confirmed by EUS-guided fine needle aspiration. Computerized tomography (CT) and EUS staging revealed vascular invasion precluding the patient from surgical resection. Cystogastrostomy was performed entirely under EUS guidance utilizing a 10-Fr double pigtail stent. After cystogastrostomy stent placement, the patient developed dramatic symptomatic improvement of gastric outlet obstructive symptoms, although subsequent imaging did not reveal complete collapse of the cystic structure. Conclusion: EUS-guided cystogastrostomy can be considered in the palliative treatment of nonresectable pancreatic cystic neoplasms. Cyst decompression may result in significant symptomatic improvement, although the architecture of malignant cysts may prevent complete resolution.

Bile duct brushings in a pig model: examination of intraobserver variability and variability in specimen quality obtained in sequential animals and between two different brushes.

SummaryPurpose. In patients with bile duct malignancy, bile duct brushing is plagued by a low yield diagnosing underlying malignancy. There are few data explaining why this is so. This porcine model was designed to examine three variables: 1) examination of inter-observer variability, 2) variability in specimen quality obtained in sequential animals, and 3) variability between two different brushes (one designed for colon with large bristles, one for duodenum with short bristles).n Methods. En bloc resection of liver, bile ducts, duodenum, and pancreas was performed on three 6-moold crossbred pigs at the time of commercial slaughter. In each pig, one common hepatic duct and one common bile duct brushing, all performed by the same investigator, were done. Ten identical vigorous passes were done with each brush (long bristle or short bristle) on virgin epithelium. Specimens were graded for cellularity by three cytopathologists who were blinded to the site or brush size. Interobserver variability as well as variability among sequential animals and between the two different brushes was compared.n Results. Interobserver variability among the three cytologists was almost nil. Cellularity obtained using the short brush alone varied from unsatisfactory to high. Cellularity obtained using the long brush alone varied from unsatisfactory to moderate. Variability of cells obtained from one pig to the next ranged from unsatisfactory to high.n Conclusions. 1) While interobserver variability was very low, variability in cellularity obtained from one pig to the next, and from one brush to the next, was very high. This sampling variability may partially explain the low yield in malignant cells in human malignant biliary brushing. Multiple brushings in one patient may alleviate part of this problem. 2) There was no advantage to either brush type (large bristle or small bristle).

Management of Asymptomatically/Minimally Symptomatic Post-ERCP Serum Liver Test Elevations: First Do No Harm

Trauma to the major papilla and transient supraphysiologic biliary tract pressure during ERCP may produce transient serum liver test elevation. Further investigation of these abnormal serum tests may be costly, potentially hazardous, and unnecessary. Transient rises in post ERCP serum liver tests may be a common epiphenomenon that requires only careful clinical observation. Our aim was to study serum liver test results collected before and after ERCP in asymptomatic (or minimally symptomatic) patients and determine the natural clinical history of these patients, without further intervention. Data were collected prospectively as part of a larger study, and this subset of data on asymptomatic patients was then analyzed separately. All patients had serum liver tests done before ERCP, and 4 and 18–24 h after ERCP. Thirty-seven patients were evaluated. Sixteen of the 36 (43%) had an abnormal serum liver test after ERCP. Fifteen of the 36 had a biliary or pancreatic papillotomy done. Whether or not a patient had a papillotomy performed did not appear to influence the incidence of abnormal transient serum liver test rise. There were no biliary stents placed in any of the patients evaluated. There were two cases of post-ERCP pancreatitis (one mild; one moderate). There were no cases of cholangitis or persistent biliary tract obstruction. In conclusion, a transient rise in ERCP serum liver tests appears common following ERCP. In the absence of significant clinical signs or symptoms, these isolated serum laboratory test abnormalities should managed expectantly.

Evaluation of Biliary Bacterial Resistance in Patients with Frequent Biliary Instrumentation, One Size Does Not Fit All

BackgroundBacteremia due to cholangitis can occur as a complication of biliary instrumentation. Biliary sepsis can result from frequent endoscopic retrograde cholangiopancreatography (ERCP).MethodsWe hypothesized that routine use of antibiotics in patients who require frequent ERCPs leads to cholangitis resistant to empiric antibiotics used to treat biliary sepsis. We retrospectively reviewed patients with frequent biliary instrumentation and blood stream infection due to cholangitis. Conventional empiric antibiotics were defined as broad-spectrum antibacterial agents predominantly used for community-acquired infections and surgical prophylaxis. Broad-spectrum antibacterial agents used for hospital-onset/multidrug-resistant infections were defined as broad-spectrum MDR antibiotics.ResultsSeventy-eight patients had bacteremia secondary to cholangitis from biliary obstruction. Over 50% of bacteria were not sensitive to conventional empiric antibiotics for biliary sepsis. Thirty-seven patients did not receive post-procedural antibiotics and forty-one patients did. Of the ones who did, 58% later had a bloodstream infection with bacteria resistant to the antibiotic used for prophylaxis, and 26 patients (63%) required a broad-spectrum MDR antibiotic for treatment. The number of ERCPs was not associated with resistance to prophylactic antibiotics (p 0.7103) or needing broad-spectrum MDR antibiotics for treatment of cholangitis-associated bacteremia (p 0.1868). Routine use of antibiotic prophylaxis after ERCP was associated with trend toward need for broad-spectrum MDR antibiotics for cholangitis-associated bacteremia, Chi-square 3.7, 0 0.0540.ConclusionBacterial resistance to conventional empiric antibiotics is an emerging problem. Blood cultures are needed to guide therapy.