Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction of gastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combined obstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associated with surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenal metal stents. Biliary cannulation is difficult in type II bilioduodenal strictures where the duodenal stenosis is located at the level of the papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenal strictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopic ultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and efficacy of endoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories and standardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction.
Bile Ducts ; Catheterization ; Cholangiopancreatography, Endoscopic Retrograde ; Constriction, Pathologic ; Drainage ; Duodenal Obstruction ; Duodenum ; Endoscopy ; Gastric Outlet Obstruction ; Humans ; Jaundice, Obstructive ; Length of Stay ; Prognosis ; Stents ; Ultrasonography

Sclerosing mesenteritis is a rare benign disease with a prevalence of 0.16–3.4% and is characterized by chronic nonspecific inflammation and extensive fibrosis in the adipose tissue of the mesentery although the exact pathogenesis is still elusive. A 65-year-old woman was referred with suspicion of an abdominal mass and biliary stones on abdominal ultrasonography and CT. Bile duct stones were confirmed by endoscopic ultrasonography and successfully treated by endoscopic retrograde cholangiography with stone removal. Furthermore, a 4.7 cm conglomerated mass on small intestinal mesentery was suspected as sclerosing mesenteritis based on the features on abdominal MRI. However, because it could not be differentiated from malignancy without histologic examination, laparoscopic excisional biopsy was performed; it showed only inflammatory cells with extensive fibrosis. Therefore, the abdominal mass was confirmed as sclerosing fibrosis and the patient was followed-up without any treatments because no mass-related symptoms accompanied the findings. Six months later, abdominal CT showed no significant change in the mass. Herein, we report a rare case of incidentally found idiopathic sclerosing mesenteritis.
Adipose Tissue ; Aged ; Bile Ducts ; Biopsy ; Cholangiography ; Endosonography ; Female ; Fibrosis ; Humans ; Immunoglobulins* ; Inflammation ; Magnetic Resonance Imaging ; Mesentery ; Panniculitis, Peritoneal ; Prevalence ; Sclerosis* ; Tomography, X-Ray Computed ; Ultrasonography

A clonorchiasis case in a captive leopard cat, Prionailurus bengalensis euptilurus, was confirmed by ultrasonographic findings and egg morphologies found in the bile juice sample in the Korea. The leopard cat was introduced from the wild habitat of Gyeongsangnam-do, to Cheongju Zoo in Cheongju-si, Chungcheongbuk-do, Korea in August 2014. Physical examinations were basically performed for quarantine and check-up health. The cat was comparatively good in health except anorexia. The cyst-like bile duct dilation and the increased echogenicity of gall bladder wall and hepatic parenchyma were observed by ultrasonography. Ultrasound-guided needle biopsy was conducted for collecting bile juice and the specimens were observed under light microscope. The numerous small trematode eggs were detected in the bile juice sample of the light microscopy. The eggs were 25–33 (28±3) μm by 18–22 (20±1) μm in size and showed typical characteristics of Clonorchis sinensis egg, i.e., a dominantly developed operculum, shoulder rim and dust-like wrinkles in surface. To treat the liver fluke infection, 20 mg/kg of praziquantel was orally administered only once to the case. Follow-up studies including fecal examinations were conducted during 2 years after treatment. But no more eggs were detected from the case. In the present study, we described the first clonorchiasis case of leopard cat, which was confirmed by ultrasonographic findings and egg morphologies from the bile juice sample in Korea.
Animals ; Anorexia ; Bile ; Bile Ducts ; Biopsy, Needle ; Cats ; Chungcheongbuk-do ; Clonorchiasis ; Clonorchis sinensis ; Ecosystem ; Eggs ; Fasciola hepatica ; Follow-Up Studies ; Gyeongsangnam-do ; Korea ; Microscopy ; Ovum ; Panthera ; Physical Examination ; Praziquantel ; Quarantine ; Republic of Korea ; Shoulder ; Ultrasonography ; Urinary Bladder

The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy. We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, real-time procedures, such as fine-needle aspiration.
Ampulla of Vater ; Bile Ducts ; Biopsy, Fine-Needle ; Cohort Studies ; Diagnosis ; Duodenum ; Head ; Humans ; Pancreatic Neoplasms ; Pathologic Processes ; Pathology ; Ultrasonography

Although endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for benign biliary diseases, this procedure is technically difficult in some conditions such as a surgically altered anatomy and gastric outlet obstruction. After a failed ERCP, a surgical or a percutaneous approach is selected as a rescue procedure; however, various endoscopic ultrasound (EUS)-guided interventions are increasingly utilized in pancreatobiliary diseases, including EUS-guided rendezvous for failed biliary cannulation, EUS-guided antegrade treatment for stone management, and EUS-guided hepaticogastrostomy for anastomotic strictures in patients with a surgically altered anatomy. There are some technical hurdles in EUS-guided interventions for benign biliary diseases owing to the difficulty in puncturing a relatively small bile duct and in subsequent guidewire manipulation, as well as the lack of dedicated devices. A recent major advancement in this field is the introduction of a 2-step approach, in which EUS-guided drainage is placed in the first session and antegrade treatment is performed in subsequent sessions. This approach allows the use of various techniques such as mechanical lithotripsy and cholangioscopy without a risk of bile leak. In summary, EUS-guided interventions are among the treatment options for benign biliary diseases; however, standardization of the procedure and development of a treatment algorithm are needed.
Bile ; Bile Ducts ; Catheterization ; Cholangiopancreatography, Endoscopic Retrograde ; Constriction, Pathologic ; Drainage ; Gastric Outlet Obstruction ; Humans ; Lithotripsy ; Ultrasonography

We present the case of a patient with biliary and duodenal atresia who showed false-negative hepatobiliary scintigraphy results. The patient was born at 37 weeks and 2 days of gestation. Her mother had undergone amnioreduction after detection of a double-bubble ultrasound sign in the fetal abdomen. At 2 days of age, total serum bilirubin level was elevated. On hepatobiliary scintigraphy 4 days later, the gallbladder was visualized from 30 min and it showed duodeno-gastric reflux at 240 min. After 24 h, the radiotracer was almost washed out in the hepatic parenchyma, but there was retention in the gastroduodenal junction. Because the biliary to duodenal transit was visible, biliary atresia seemed unlikely. Abdominal ultrasonography at 7 days of age showed a small dysmorphic gallbladder, but triangular cord sign was not definite. Magnetic resonance cholangiography revealed atretic gallbladder. Although cystic and common bile ducts were visible, the proximal common hepatic bile duct was not visible. The next day, serum total bilirubin levels remained elevated (17.1 mg/dl) with direct bilirubin level of 1.2 mg/dl. Kasai portoenterostomy with duodeno-duodenostomy was performed at 10 days of age. Histopathological evaluation showed a fibrous obliteration of the common bile duct, consistent with that of biliary atresia.
Abdomen ; Bile Ducts ; Biliary Atresia ; Bilirubin ; Cholangiography ; Common Bile Duct ; Duodenogastric Reflux ; Gallbladder ; Humans ; Infant, Newborn ; Jaundice, Neonatal ; Mothers ; Pregnancy ; Radionuclide Imaging ; Ultrasonography

This study describes ultrasonographic observations of five hepatobiliary diseases in buffalo (Bubalus bubalis). Fifty buffalo, including 20 clinically normal and 30 hepatobiliary diseased buffalo were enrolled in the study. Complete clinical, radiographic and ultrasonographic examinations and laboratory analyses were conducted. Focal parenchymal lesions including liver abscess (n = 12) and hepatic cyst (n = 6), diffuse parenchymal lesion (hepatobiliary cirrhosis, n = 5) and obstruction of hepatobiliary passages including cholestasis (n = 4), and hepatocholelithiasis (n = 3) were successfully imaged by ultrasonography. Hepatic abscess imaged as a hypoechoic to echogenic circumscribed mass of various diameters with a distinct echogenic capsule. Hepatic cyst imaged as a pear-shaped sac with a bright echogenic margin, anechoic content, and distal acoustic enhancement. In hepatobiliary fibrosis, the liver showed linear bands of increasing echogenicity with less distinct imaging of the portal vasculature. Cholestasis was imaged as dilatation of the gallbladder (GB) with wall thickening and homogeneous or heterogeneous contents. Hepatocholelithiasis imaged as an echoic structure within the hepatic parenchyma, or within and around the GB and bile duct, with more echogenicity of the hepatic parenchyma than normal. Ultrasonography can be an efficient rapid, noninvasive tool for screening of common hepatobiliary diseases in buffalo under field conditions.
Acoustics ; Bile Ducts ; Buffaloes ; Cholestasis ; Dilatation ; Fibrosis ; Gallbladder ; Liver ; Liver Abscess ; Mass Screening ; Ultrasonography

Endoscopic ultrasound (EUS) has become an essential tool for the diagnostic and therapeutic intervention of gastrointestinal diseases. Beyond the drainage of fluid collections, it enables decompression of inaccessible bile and pancreatic ducts, the gallbladder, and the creation of anastomosis within the gastrointestinal tract using fully lumen-apposing stents. This review explored the safety and efficacy of these novel procedures and discussed the training pathway that is necessary to perform them efficiently and safely.
Bile ; Decompression ; Drainage ; Endosonography ; Gallbladder ; Gastrointestinal Diseases ; Gastrointestinal Tract ; Pancreatic Ducts ; Stents ; Ultrasonography*

PURPOSE: The aim of this study was to describe our treatment experiences with patients who had acute abdomen (AA) with common bile duct (CBD) dilatation. METHODS: The treatment outcomes in children with AA and CBD dilatation were retrospectively reviewed. According to the shape of the intrahepatic bile ducts on ultrasonography (US), the origin of the pain was estimated as choledochal cyst (CC) complication or choledocholithiasis in normal CBD. Patients with complicated CC underwent surgery, and patients with choledocholithiasis in a normal appearing CBD underwent symptomatic treatment initially. RESULTS: Of the 34 patients, 30 (88.2%) were female. The mean age of the patients was 6.4±4.9 (range, 0.8–17) years. Seventeen (50.0%) patients had CBD stones and 17 (50.0%) did not. Surgical treatment was performed in 20 (58.8%) patients, 2 of whom underwent preoperative stone removal with endoscopic retrograde cholangiopancreatography and an operation. Conservative treatment was applied in 12 (35.3%) patients (8 with and 4 without stones), 1 of whom developed symptom relapse and underwent an operation. Among the 8 patients with CBD stones, 4 (4/17, 23.5%) had complete resolution of the stones and recovery of the CBD diameter after conservative treatment. US findings of patients with stone showed a fusiform or cylindrical shape of the CBD in 14 (82.4%) patients. CONCLUSION: The presence of stones in the distal CBD and the US features of CBD dilatation may be helpful to diagnose and treat the causes of biliary dilatation. Conservative treatment can be considered as initial therapy in patients with uncomplicated CBD dilatation with stone.
Abdomen, Acute* ; Bile Ducts, Intrahepatic ; Child ; Cholangiopancreatography, Endoscopic Retrograde ; Choledochal Cyst ; Choledocholithiasis ; Common Bile Duct* ; Dilatation* ; Female ; Humans ; Recurrence ; Retrospective Studies ; Ultrasonography

Although asymptomatic bile duct dilatation was commonly found in clinical practice due to the development of imaging devices and frequent health screening examination, it is sometimes difficult to distinguish between normal and abnormal. In evaluating the cause of bile duct dilatation, comprehensive approach should be accompanied, instead of determining by using any one of imaging modalities. Before diagnosing bile duct dilatation, physiologic changes due to aging and history of biliary operation might be considered. The acceptable range for normal diameter of bile duct is 7-8 mm in transabdominal ultrasonography and less than 10 mm in cholangiography. However, the diameter of bile duct in elderly is acceptable up to 10 mm and 12 mm, respectively. Among patients with incidentally found bile duct dilation, further additional image studies are required to confirm the cause of bile duct dilatation in case of presence of symptom and abnormal liver function test. Meanwhile, the truly asymptomatic patient with normal liver enzyme profiles should be followed closely with clinical and laboratory follow-up to help decide whether any additional imaging would be appropriate.
Aged ; Aging ; Bile Ducts* ; Bile* ; Cholangiography ; Dilatation* ; Endosonography ; Follow-Up Studies ; Humans ; Liver ; Liver Function Tests ; Mass Screening ; Ultrasonography