Pneumobilia almost always indicates an abnormal communication between the biliary and gastrointestinal systems. Air may occasionally enter the biliary tract in a retrograde fashion through the papilla. Transient incompetence of the sphincter of Oddi, which is produced by the passage of small biliary stones, is one rare mechanism that can explain pneumobilia. We present here a case of spontaneous pneumobilia after sphincter disruption that was presumably caused by the passage of biliary stone. A 37-year-old woman visited our hospital with the symptom of right upper quadrant pain. The pain subsided after she had an episode of severe vomiting. Plain abdominal radiography revealed that air filled the branches of the hepatic ducts, and the common bile duct had a large filling defect. We also include a review of the related literature.
Adult ; Biliary Tract ; Common Bile Duct ; Female ; Hepatic Duct, Common ; Humans ; Radiography, Abdominal ; Sphincter of Oddi ; Vomiting

Biliary complications after orthotopic liver transplants are a continuing cause of morbidity and mortality. Biliary stones and sludge are less well known complications of hepatic transplantation, although they have long been recognized. Recently we experienced two cases of biliary stones developed after liver transplantation. One 32-year-old male, who frequently admitted due to recurrent cholangitis, was treated with percutaneous transhepatic biliary drainage and choledochojejunostomy with cholecystectomy. The other 58-year-old male, who had stones in commone bile duct, was treated by endoscopic manipulation. They are in good condition without recurrent bile duct stones or its accompanying complications. Although stones and sludge are relatively infrequent after liver transplantation, surgical or interventional radiologic treatments are usually performed for treatment.
Adult ; Case Report ; Common Bile Duct Calculi/ultrasonography ; Common Bile Duct Calculi/radiography ; Common Bile Duct Calculi/etiology* ; Human ; Liver Transplantation/adverse effects* ; Male ; Middle Age ; Tomography, X-Ray Computed/methods

Retrograde endoscopic or percutaneous transhepatic bile duct drainage is the treatment of choice for palliation of malignant biliary obstruction. An expanding metal stent, Endocoil spiral stent, with strong radial force was developed to solve the problems of other metal stents which include obstruction by tumor ingrowth, migration, and epithelial trauma from the distal hard edges of the stent. A choledochoduodenal fistula is occasionally found during endoscopic retrograde cholangiopancreatiography (ERCP) or barium radiography. Cholelithiasis is suspected to be the leading cause in some endemic areas like Korea but duodenal ulcer is more common in Western countries. The case reported here is of a 78-year-old woman, suffering from vomiting, epigastric pain, and abdominal distension, who had a Endocoil spiral stent in the common bile duct (CBD) for pancreatic head cancer for 8 months. During barium radiograph, a fistulous connection between the proximal second part of duodeum and the CBD was identified.
Aged ; Barium ; Bile Ducts ; Cholelithiasis ; Common Bile Duct ; Drainage ; Duodenal Ulcer ; Female ; Fistula* ; Head and Neck Neoplasms* ; Head* ; Humans ; Korea ; Radiography ; Stents* ; Vomiting

Amputation neuroma or traumatic neuroma is a tumor-like secondary hyperplasia that may develop after an accidental or surgical trauma. Amputation neuroma of the bile duct has occasionally been reported which occurred in the cystic duct stump late after the cholecystectomy. However, even if the amputation neuroma is suspected in a patient with late-onset jaundice after cholecystectomy, the differential diagnosis from a malignancy is difficult preoperatively. We experienced a case of the amputation neuroma of common bile duct (CBD) developed in a 70-year-old man who presented with a polypoid mass in CBD. He had undergone cholecystectomy 25 years ago and choledochojejunostomy 12 years ago, respectively. We have performed pylorus-preserving pancreatico-duodenectomy (PPPD) under the impression of CBD cancer. He had not been diagnosed of amputation neuroma until having undergone PPPD. We report a case of CBD neuroma mimicking CBD cancer, which was confirmed after PPPD.
Aged ; Common Bile Duct Neoplasms/*diagnosis/radiography ; Diagnosis, Differential ; Humans ; Male ; Neuroma/*diagnosis/pathology/radiography ; Pancreaticoduodenectomy ; S100 Proteins/immunology ; Tomography, X-Ray Computed

Small cell carcinoma is usually seen in the lung, but rarely involves the gastrointestinal tract including biliary tract. A 65 year-old man was admitted because of obstructive jaundice. A smooth-surfaced round intraluminal mass with proximal bile duct dilatation was seen in the proximal common bile duct on endoscopic retrograde cholangiogram. Under the diagnosis of bile duct cancer, pylorus-preserving pancreatoduodenectomy was done. Pathology revealed a 2 cm sized small cell carcinoma in the proximal common bile duct and distal common hepatic duct. On immunohistochemical stain, the tumor cells were positive for neuroendocrine markers CD56 and synaptophysin. After surgery, the patient received 5 cycles of adjuvant chemotherapy with VIP (etoposide, ifosfamide, and cisplatin) regimen. However, the patient died of liver metastasis 12 months after the diagnosis. We report a case of extrapulmonary small cell carcinoma arising from the common bile duct.
Aged ; Bile Duct Neoplasms/complications/*diagnosis/surgery ; Carcinoma, Small Cell/complications/*diagnosis/surgery ; Cholangiopancreatography, Endoscopic Retrograde ; *Common Bile Duct/radiography/radionuclide imaging/surgery ; Fatal Outcome ; Humans ; Liver Neoplasms/diagnosis/secondary ; Male ; Positron-Emission Tomography ; Tomography, X-Ray Computed

Obstructive jaundice by vascular compression is rare. The causative arteries were identified as the right hepatic artery, gastroduodenal artery, cystic artery, proper hepatic artery, and an unspecified branch of the common hepatic artery. Also the venous system, such as enlarging collateral veins in cases of portal hypertension was a causative vessel. Herein, we describe a case of a proximal choledocholithiasis due to compression of the common bile duct by right hepatic artery originated from gastroduodenal artery. Final diagnosis and treatment were achieved through an operation.
Cholangiography ; Common Bile Duct/blood supply/*pathology/surgery ; Diagnosis, Differential ; *Hepatic Artery ; Humans ; Jaundice, Obstructive/*diagnosis/etiology/radiography ; Male ; Middle Aged ; Tomography, X-Ray Computed

OBJECTIVETo investigate the early diagnosis on iatrogenic injuries in distal part of common bile duct and the prevention of severe retroperitoneal infection.

METHODSFrom 1990 to 2004, 17 patients with bile duct injures in the distal part of common biliary tract were admitted. And the clinical data of the 17 cases were retrospectively analyzed.

RESULTSOf the 17 cases, the injuries of 15 cases were caused by the operation, and the injuries of the other 2 cases were caused in the process of removing the stone by endoscopic retrograde cholangiopancreatography (ERCP). The injuries of 14 cases were found during the operation, but the other one was not found in time. Before the operation, 16 cases were examined by B-type ultrasonography, 2 by MRCP and 6 by intraoperative choledocho-endoscope after the biliary tract exploration. Ten cases underwent perforating suture repair and T-tube drainage; 2 with Odd's sphincter incision and shaping; 2 with choledochojejunostomy; 1 with duodenum wall and bile duct repair and drainage. When the bile duct injured, the major findings during operation were bile duct explorer located out of the duodenum wall and bile duct, two or more than cleft in the distal part of common biliary tract found by choledocho-endoscopic examination, retroperitoneal edema and liquid accumulation found by irrigating water through T-tube, and/or retroperitoneal tissues stained blue by irrigating methylthioninium chloride through T-tube. The clinical manifestations after injuries were abdominal distention, abdominal pain, pain in the waist and back, fever and shock, et al. Thirteen cases were cured. And the syndromes included 1 case with intestinal fistula, 1 with incisional infection, 4 dead (3 died from infectious shock; 1 from bleeding in gastrectomy).

CONCLUSIONSThe postoperative clinical manifestations for iatrogenic injuries in the distal part of common biliary tract lack specificity, CT examinations are necessary to doubtful patients. Early diagnosis and timely management can obtain better results, and can effectively lower severe retroperitoneal infection. The perfect preoperative imaging examinations and intraoperative choledocho-endoscopic examinations before the biliary tract exploration maybe reduce iatrogenic injuries in the distal part of common biliary tract.

Adult ; Aged ; Common Bile Duct ; injuries ; surgery ; Female ; Humans ; Iatrogenic Disease ; prevention & control ; Intraoperative Complications ; diagnostic imaging ; surgery ; Male ; Middle Aged ; Peritonitis ; prevention & control ; Radiography ; Retrospective Studies

A 75-year-old woman with hypertension presented with acute suppurative cholangitis. Chest radiography revealed severe kyphosis. Abdominal computed tomography revealed a large stone impacted in the common bile duct (CBD). The patient underwent emergent endoscopic retrograde cholangiopancreatography, and cholangiography revealed a large stone (7×3 cm) in the CBD that could not be captured using a large basket. We could not use the percutaneous approach for stone fragmentation by using a cholangioscope because of severe degenerative kyphosis. Finally, we performed holmium laser lithotripsy under peroral cholangioscopy by using an ultraslim endoscope, and the large stone in the CBD was successfully fragmented and removed without complications.
Aged ; Cholangiography ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis ; Common Bile Duct* ; Endoscopes ; Female ; Gallstones ; Humans ; Hypertension ; Kyphosis* ; Lasers, Solid-State ; Lithotripsy ; Lithotripsy, Laser* ; Radiography ; Thorax

We report a rare case of a massive fatal embolism that occurred in the middle of endoscopic retrograde cholangiopancreatography (ERCP) and retrospectively examine the significant causes of the event. The patient was a 50-year old female with an uncertain history of previous abdominal surgery for multiple biliary stones 20 years prior. The patient presented with acute right upper quadrant pain. An abdominal computed tomographic (CT) scan revealed the presence of multiple stones in the common bile duct (CBD) and intra-hepatic duct (IHD) with biliary obstruction, multifocal liver abscesses, and air-biliarygram. Emergency ERCP showed a wide and straight opening of choledochoduodenostomy, which may have been created during a previous surgery, and multiple filling defects in the CBD. With the use of a forward endoscope, mud stones were extracted through the opening of the choledochoduodenostomy. Cardiac arrest suddenly developed during the procedure, and despite immediate resuscitation, the patient died due to a massive systemic air embolism. We reviewed previously reported fatal cases and accessed factors facilitating air embolisms in this case.
Cholangiopancreatography, Endoscopic Retrograde/*methods ; Choledochostomy/*methods ; Common Bile Duct/radiography ; Embolism, Air/*complications ; Fatal Outcome ; Female ; Humans ; Liver Abscess/pathology ; Middle Aged ; Tomography, X-Ray Computed

Korean autoimmune pancreatitis (AIP) criteria 2007 was aimed to diagnose the wide spectrum of AIP with high sensitivity. The most crucial issue when caring for patients with suspected AIP is to differentiate AIP from pancreatic cancer. Pancreatic cancer can be distinguished from AIP by pancreatic imaging, measurement of serum IgG4 levels, endoscopic ultrasound guided fine needle aspiration and trucut biopsy, and steroid trial. Autoimmune pancreatitis is a rare systemic fibroinflammatory disease which can affect not only the pancreas, but also a variety of organs such as the bile ducts, salivary glands, retroperitoneum, and lymph nodes. Organs affected by AIP have a lymphoplasmacytic infiltrate rich in IgG4-positive cells. This inflammatory process responds dramatically to oral steroid therapy. Granulocytic epithelial lesion (GEL) positive AIP patients differ from GEL negative AIP patients in clinical features such as equal gender ratio, younger mean age, no increase in serum IgG4, no association with extrapancreatic involvement, no relapse, and frequent association with inflammatory bowel disease. Further investigation is needed to clarify the pathogenic mechanisms including more definite serological markers for theses two entities.
Autoimmune Diseases/*diagnosis/pathology/ultrasonography ; Common Bile Duct/radiography ; Fibrosis/pathology ; Humans ; Immunoglobulin G/blood ; Pancreatitis/*diagnosis/pathology/ultrasonography ; Salivary Glands/pathology