Search Results (32)

Background: Ischemic cholangiopathy (IC) is an under-recognized complication after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). Our goal was to estimate the incidence, timing, clinical presentation, and management of IC after drug-eluting bead TACE. Methods: Single-center retrospective cohort of consecutive drug-eluting bead TACE procedures (1 January 2020–31 December 2023) with imaging follow-up to 31 December 2024 was conducted. IC was defined radiologically as bile duct dilatation without mechanical obstruction, biloma formation, biliary strictures, or ischemic cholecystitis occurring after TACE. The primary outcome was the incidence of IC. Secondary outcomes included clinical presentation, need for hospitalization, and management. Results: Among 106 patients, 14 developed IC (13.2%). Imaging abnormalities were detected a mean of 3.1 months after TACE. Six patients (42.9%) were asymptomatic. Among symptomatic patients, the most common manifestations were abdominal pain (n = 6) and fever (n = 4). Five patients required hospitalization, including 2 with infected bilomas requiring antibiotics and/or drainage. Subsequent HCC therapy was feasible in most cases; no deaths were directly attributed to IC. Conclusions: IC after TACE is not rare and is frequently asymptomatic, often detected incidentally on routine CT follow-up. Systematic biochemical monitoring and selective MRCP could improve detection, particularly when TACE sessions are closely spaced. Full article

Background/Objectives: Post-cholecystectomy syndrome (PCS) remains diagnostically challenging due to overlapping biliary and non-biliary causes. This study aimed to evaluate whether common bile duct (CBD) diameter measured by MRCP can serve as a practical triage parameter in symptomatic PCS patients and to define a data-supported threshold for predicting clinically relevant biliary pathology. Secondary objectives included assessing correlations between MRCP findings and upper endoscopic features. Methods: In this retrospective single-center study, symptomatic adults undergoing upper endoscopy and MRCP were analyzed. Demographic, clinical, biochemical, radiologic, and endoscopic variables were recorded. Diagnostic performance was assessed using ROC analysis, and independent predictors of biliary dilatation were evaluated with multivariable logistic regression. Results: We analyzed 141 symptomatic post-cholecystectomy patients (mean age 58.2 ± 16.3 years; 67.4% female; median time since surgery 18 [9–36] months). Major symptoms: abdominal pain 84.9%, dyspepsia/bloating 47.5%, nausea/vomiting 22.3%, diarrhea 15.1%. CBD diameter measurements were available in the MRCP subgroup (n = 45); ERCP was performed selectively (n = 12). MRCP findings: CBD ≥ 7 mm 31.9%, biliary dilatation 14.9%, stricture 2.8%, suspected Oddi dysfunction 11.3%, postoperative complications 39.7%. Endoscopy: mucosal inflammation 91.5%; normal 8.5%. Significant correlations included CBD diameter vs. mucosal inflammation (r = 0.32, p = 0.001), dilatation vs. bile reflux (r = 0.28, p = 0.004), and Oddi dysfunction vs. papillary edema (r = 0.41, p = 0.001). CBD diameter showed the best diagnostic performance (AUC 0.82, 95% CI 0.74–0.90; cut-off ≥ 8.0 mm; sensitivity 78.3%; specificity 81.5%; p < 0.001). In multivariable analysis, age independently predicted biliary dilatation (OR 1.05 per year; 95% CI 1.01–1.09; p = 0.007). Conclusions: In symptomatic post-cholecystectomy patients, MRCP-measured CBD diameter provides a useful metric for risk stratification, with a threshold of ≥8 mm identifying patients more likely to harbor biliary pathology. These findings support a structured diagnostic approach that prioritizes noninvasive imaging while reserving ERCP for selected cases. Further prospective validation is warranted. Full article

Background/Objectives: The diagnostic management of obstructive pancreatobiliary pathologies often leads to unnecessary invasive procedures and the overuse of costly imaging due to inherent diagnostic uncertainties. This dilemma highlights the need for a refined triaging strategy. This study aimed to compare the diagnostic competence and triage potential of Transabdominal Ultrasonography (TAUS)—a cost-effective, first-line method—with the efficacy of the invasive method, Endoscopic Ultrasonography (EUS). Our objective was to identify specific TAUS findings that could render EUS redundant or serve as a clinical guide for referral to EUS. Methods: This prospective study included patients evaluated for suspected pancreatobiliary lesions (December 2024–September 2025). Final diagnoses (gold standard) were established using pathology, tumor board decisions, other imaging, or ≥6 months clinical follow-up. TAUS was performed by one operator blinded to clinical data. EUS was immediately performed by a different operator, blinded to TAUS results and all other clinical data. Data were grouped into normal findings, solid masses, cystic lesions, chronic pancreatitis, distal cholangiocarcinoma/ampullary tumors, and choledocholithiasis. Results: A total of 204 patients were included. TAUS sensitivity (76.5%) was significantly lower than EUS (94.6%) (p < 0.001), but both showed high specificity (TAUS: 82.9%; EUS: 88.24%). TAUS performance varied greatly by lesion type: high for solid lesions (81.8%) and chronic pancreatitis (88.9%), but markedly lower for distal common bile duct lesions/ampullary tumors (57.1%; p = 0.006). In univariate analysis, BMI (p < 0.001), lesion size (p = 0.002), MPD dilation (p = 0.001), and localization (p < 0.001) were associated with TAUS success. Lesion size (OR = 1.049, p = 0.029) was the independent predictor in the multivariate analysis. TAUS detected common bile duct dilation in obstructive cases at a high rate (95.9%) but had statistically significantly lower success in reaching a definitive diagnosis (63.3%; p < 0.001). Conclusions: While TAUS lacks the overall sensitivity of EUS, its robust detection performance for solid lesions and chronic pancreatitis suggests that it can reduce the need for further investigation in selected cases. The TAUS detection success, associated with factors like BMI and lesion size, combined with its high rate of common bile duct dilation detection, establishes a reliable triage guideline for referring patients to advanced diagnostic procedures, primarily EUS, to confirm the definitive etiology. Full article

The indications for biliary drainage in cases of pancreatic head tumors with biliary obstruction are well established. ERCP with stent placement has long been the gold standard technique, outperforming surgery or percutaneous drainage. However, in cases of distal malignant biliary obstruction, ERCP becomes more complex, increasing the risk of complications. The advent of therapeutic endoscopic ultrasound (EUS), particularly EUS–choledochoduodenostomy (EUS-CDS) and EUS–hepaticogastrostomy (EUS-HGS), has transformed the management of distal malignant biliary obstruction in the case of pancreatic cancer. EUS-CDS creates communication between the duodenum and the common bile duct. Lumen-apposing metal stents (LAMSs) simplify the procedure, offering high technical and clinical success rates and making the technique easier to perform. Nevertheless, long-term dysfunction rates remain high, necessitating careful definition of procedural indications. EUS-HGS, a more complex technique, connects dilated left bile ducts to the stomach and requires advanced expertise; it is associated with a higher rate of complications. However, its clinical efficacy and technical success are comparable to those of EUS-CDS, and it is the preferred technique in cases of duodenal obstruction or altered anatomy. European and American guidelines currently position EUS-guided biliary drainage (EUS-BD) as a second-line approach after ERCP failure or when ERCP is not feasible, but there is a growing trend toward earlier use. Other techniques are emerging, such as EUS-guided gallbladder drainage (EUS-GBD) and combining EUS-HGS with antegrade stenting, offering valuable alternatives when conventional techniques fail or are inaccessible. Full article

A 2-year-old male neutered domestic shorthair cat was presented with a 12-month history of anorexia, weight loss, vomiting, polyuria, and polydipsia. Physical examination revealed a responsive but debilitated cat with icteric mucous membranes and a low body-condition score. Laboratory tests showed mild macrocytic anemia, elevated liver enzymes, hyperproteinemia with hypoalbuminemia, hyperbilirubinaemia, and a decreased vitamin B12 level. Abdominal ultrasound revealed marked dilation of the common bile duct (CBD) and gallbladder, consistent with suspected extrahepatic biliary tract obstruction, as well as secondary pancreatic and intrahepatic duct distension. Cytological and bacteriological analyses confirmed bacterial cholangiohepatitis due to a mixed infection with Escherichia coli and Peptostreptococcus canis. Despite initial conservative management, the cat’s clinical condition remained unchanged, prompting exploratory laparotomy. Intraoperative findings confirmed the ultrasonographic suspicions and revealed severe pancreatitis. Based these findings, a cholecystectomy, choledochoenterostomy, and placement of a cholecystostomy tube as well as an abdominal drain and jejunal feeding tube were performed. Postoperatively, the cat initially showed improvement but subsequently developed signs of sepsis requiring intensive care. Although temporary stabilization was achieved, the cat died suddenly ten days after surgery due to unknown causes. This case report highlights the diagnostic and therapeutic challenges associated with bacterial cholangiohepatitis secondary to biliary obstruction in cats and documents the first clinical application of choledochoenterostomy—a surgical procedure previously only described hypothetically in this species. Full article

Background/Objectives: The combined techniques of endoscopic sphincterotomy followed by endoscopic papillary balloon dilation (ESBD) and endoscopic sphincterotomy followed by endoscopic papillary large balloon dilation (ESLBD) have gained popularity for the endoscopic treatment of choledocholithiasis. However, the conventional approach to these procedures requires two separate devices, a sphincterotome and a balloon catheter, which can complicate and prolong the procedure. We herein evaluated a novel integrated device combining a sphincterotome and balloon catheter developed to improve the efficiency of ESBD and ESLBD. Methods: This retrospective study compared the clinical outcomes of patients with choledocholithiasis who were treated using conventional sphincterotome and balloon catheters (n = 106) and those who were treated using the integrated device (n = 54). Results: Overall complete stone removal rates (99.1% vs. 100%) and adverse event incidence (12.3% vs. 13.0%) were comparable between the two groups. However, the integrated device significantly reduced total procedure time (40 vs. 27 min, p = 0.01), use of mechanical lithotripter (50.0% vs. 22.2%, p < 0.01), total number of procedures required. Conclusions: Complete stone removal rates and safety were comparable between the two groups. However, the novel integrated device may enhance the efficiency of common bile duct stone removal through ESBD and ESLBD because it eliminates the need to prepare and exchange separate devices. Full article

Two geriatric (>9 years old) dogs presented with vomiting, depression, and anorexia and were diagnosed with extrahepatic biliary obstruction (EHBO) secondary to ruptured gallbladder mucoceles. Diagnosis was based on serum biochemical analysis, abdominal radiography, and ultrasonography, which revealed gallbladder rupture, peritonitis, and common bile duct dilation. Both dogs underwent emergency surgical intervention involving cholecystectomy and choledochal stent placement in the common bile duct without cholecystojejunostomy or cholecystoduodenostomy. Postoperatively, the clinical symptoms and serum chemistry values improved, and both dogs survived without recurrence for over one year. These cases demonstrate that choledochal stenting can be an effective adjunct to cholecystectomy for managing EHBO in dogs with ruptured gallbladder mucoceles, potentially preventing reocclusion and promoting recovery, especially when histopathological evaluation is not feasible in clinical settings. However, persistent elevation of liver enzymes may occur postoperatively, necessitating prolonged monitoring and medical management in some cases. Full article

Objectives: Most studies assess risk factors for common bile duct (CBD) stones in patients with gallbladder in situ. We aimed to assess risk factors for CBD stones in patients with previous cholecystectomy in a proof-of-concept study. Methods: We enrolled consecutive patients undergoing EUS for suspected symptomatic CBD stones and recorded demographic variables, clinical presentation, liver function tests (LFTs), and transabdominal ultrasound (US) findings. EUS was used as gold standard for CBD stones. Multivariate analysis was used to identify risk factors in the training set; a model was created and tested on the validation set. Results: A total of 211 patients (25.6% male; median age, 66 [49–75] years old) were enrolled; 77.7% presented with abdominal pain, 30.3% with hyperbilirubinemia, 26.5% with pancreatitis, and 61.1% with LFT alterations. Ultrasound showed CBD dilation in 37.4% patients. Overall, 96 (45.5%) patients had CBD stones. According to multivariate analysis, male gender (OR 2.54 [1.26–5.09]; p = 0.009), age > 63 years (OR 3.06 [1.63–5.72]; p < 0.001), LFT alteration (OR 2.62 [1.40–4.91]; p = 0.003), and CBD dilation (OR 2.46 [1.31–4.65]; p = 0.005) were independently related to CBD stones. A model was created based on the number of risk factors on admission; patients with no risk factor had a 9.5% prevalence of CBD stones; those with one risk factor, 26.7%; two risk factors, 53.2%; three risk factors, 66.7%; and four risk factors, 100%. Conclusions: The results of this proof-of-concept study identify male gender, age, LFT alteration, and CBD dilation as risk factors for CBD stones in patients with previous cholecystectomy. An adequate assessment of the pre-test probability will guide patients’ subsequent management. Full article

Purpose: Forme fruste choledochal cyst (FFCC) is a choledochal cyst with minimal or no dilatation of the extrahepatic bile duct (EHBD) and is usually associated with an anomalous pancreaticobiliary junction (APBJ). While sharing similar symptoms, inflammation, and malignant potential with classic biliary cysts, FFCC is often overlooked on ultrasound. This paper aims to present the experience of two tertiary pediatric centers in managing FFCC. Methods: In this retrospective study, the clinical data of pediatric patients treated for FFCC at two tertiary pediatric surgical centers between 1 January 2008 and 31 December 2023 were analyzed. The primary outcome was the clinical success of the surgical procedure, defined by the resolution of symptoms and the absence of major complications. Secondary outcomes included postoperative complications, type and duration of surgical procedures, and length of hospital stay. All patients underwent biliary reconstruction via either Roux-en-Y hepatico-jejunostomy or hepatico-duodenostomy. Clinical outcomes, including postoperative complications and patient follow-up, were evaluated. Results: Fourteen children (9 girls, 5 boys; aged 18 months to 12 years) underwent surgical treatment of FFCC. The mean age at surgery was 5.3 ± 3.8 years, and the mean diameter of the common bile duct was 7.9 ± 1.2 mm. Thirteen patients underwent Roux-en-Y hepatico-jejunostomy, and one underwent hepatico-duodenostomy. Over a mean follow-up period of 6.2 ± 3.6 years, no cholangitis or anastomotic stricture cases were observed. Two patients (14.3%) experienced minor wound infections managed conservatively. Conclusions: FFCC remains a diagnostic challenge due to its subtle imaging findings and non-specific clinical presentation. However, once identified, surgical excision with biliary reconstruction, most commonly via Roux-en-Y hepatico-jejunostomy, is a safe and effective treatment with excellent long-term outcomes. Given the potential for serious complications if left untreated, FFCC should be actively considered in pediatric patients with unexplained pancreatitis or biliary symptoms, even in the absence of overt ductal dilatation. Full article

This review aims to summarize the role of endoscopic therapy in the management and outcomes of recurrent acute pancreatitis (RAP). RAP is a clinical entity characterized by repeated episodes of acute pancreatitis in the setting of a normal gland or chronic pancreatitis (CP). The aetiology of RAP can be identified in about 70% of cases; for the remaining cases, the term “idiopathic” (IRAP) is used. However, advanced diagnostic techniques may reduce the percentage of IRAP to 10%. Recognized causes of RAP are gallstone disease, including microlithiasis and biliary sludge, sphincter of Oddi dysfunction (SOD), pancreatic ductal abnormalities (either congenital or acquired) interfering with pancreatic juice or bile outflow, genetic mutations, and alcohol consumption. SOD, as a clinical entity, was recently revised in the Rome IV consensus, which only recognized type 1 dysfunction as a true pathological condition, while type 2 SOD was defined as a suspected functional biliary sphincter disorder requiring the documentation of elevated basal sphincter pressure to be considered a true clinical entity and type 3 was abandoned as a diagnosis and considered functional pain. Endoscopic therapy by retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) has been proven effective when a mechanical obstruction is found and can be removed. If an obstruction is not documented, few treatment options are available to prevent the recurrence of pancreatitis and progression toward chronic disease. In gallstone disease, endoscopic biliary sphincterotomy (EBS) is effective when a dilated common bile duct or biliary sludge/microlithiasis is documented. In type 1 SOD, biliary or dual sphincterotomy is generally successful, while in type 2 SOD, endotherapy should be reserved for patients with documented sphincter dysfunction. However, in recent years, doubts have been expressed about the real efficacy of sphincterotomy in this setting. When sphincter dysfunction is not confirmed, endotherapy should be discouraged. In pancreas divisum (PD), minor papilla sphincterotomy is effective when there is a dilated dorsal duct, and the success rate is the highest in RAP patients. In the presence of obstructive conditions of the main pancreatic duct, pancreatic endotherapy is generally successful if RAP depends on intraductal hypertension. However, despite the efficacy of endotherapy, progression toward CP has been shown in some of these patients, mainly in the presence of PD, very likely depending on underlying genetic mutations. In patients with IRAP, the real utility of endotherapy still remains unclear; this is because several unknown factors may play a role in the disease, and data on outcomes are few, frequently contradictory or uncontrolled, and, in general, limited to a short period of time. Full article

Background/Objectives: Pancreatitis is the most frequent and serious complication of endoscopic retrograde cholangiopancreatography (ERCP), with an incidence between 2 and 10% and a mortality rate of 1 in 500 patients. Etiopathogenesis remains poorly understood. The aim of this study was to analyze the incidence of post-ERCP pancreatitis (PEP) and to identify potential patient- and procedure-related risk factors (RF) in a cohort of patients from a tertiary referral center in Romania. Methods: We conducted a retrospective, observational, single-center study in which we analyzed ERCP procedures performed in the Gastroenterology Department of Colentina Clinical Hospital, Bucharest, Romania, between January 2019 and September 2024. All patients received intrarectal diclofenac before the ERCP and were hydrated with at least 1500 mL of Ringer’s solution after the procedure in the absence of contraindications, according to the latest international recommendations. Results: In total, 2743 ERCPs were performed in the given time period, while 2350 procedures were analyzed in the study. PEP occurred in 350 cases (14.9%). Of these, 191 (54.6%) occurred in males with a mean age of 66.5 years. Procedural RF with adjusted odds ratios (OR) were as follows: difficult cannulation of the common bile duct, OR = 3.734, p < 0.001, main pancreatic duct catheterization, OR = 1.454, p = 0.022, and endoscopic papillary balloon dilatation, with an OR of 3.258, p < 0.001. Pancreatic duct stent placement was shown to prevent PEP in this study group (p < 0.001). Conclusions: PEP remains a serious complication of ERCP, associated with significant morbidity and occasional mortality. While some proven risk factors, such as age, gender, or comorbidities, are unmodifiable, avoiding Wirsung duct cannulation and pancreatography, or prophylactic pancreatic duct stent placement, could play a significant role in PEP prevention. Full article

Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life. Full article

Purpose: To assess (I) whether, in autopsy-proven lethal intoxications with opiates/opioids, a dilatation of the common bile duct (CBD) is still visible in postmortem computed tomography (PMCT) and (II) if a dilatation of the CBD might also be measurable for other substance groups (e.g., stimulants, hypnotics, antipsychotics, etc.). Methods: We retrospectively measured the CBD using PMCT in cases with lethal intoxication (n = 125) and as a control group in cases with a negative toxicological analysis (n = 88). Intoxicating substances were classified into the subgroups (opiates, opioids, stimulants, hypnotics, antipsychotics, gasses, and others). Significance between the study and control groups was tested with the Mann–Whitney U test, and correlations were examined by using crosstables. Results: There was a statistically significant difference between the CBD diameters in the intoxication group overall, when compared to the CBD diameter in the control group (p < 0.001). For both subgroups of “opiates” and “opioids”, there was a strong statistically significant difference between the CBD diameter (being wider) in those groups compared to the control group (both p = 0.001). For the three subgroups “hypnotics”, “stimulants”, and “psychotropic drugs”, there was no statistically significant difference between the CBD diameters in the intoxication subgroups when compared with the control group. The other subgroups were too small for statistical analysis. Conclusion: A dilated common bile duct in postmortem computed tomography might be used as an indication for a lethal opioid or opiate intoxication only in regard to the specific case circumstances or together with other indicative findings in a postmortem investigation. Full article

This report describes the successful intrahepatic duct incision and closure for the treatment of multiple cholelithiasis in a dog with untreated hypothyroidism. A 12-year-old spayed female Spitz dog weighing 11.3 kg was diagnosed with multiple cholelithiasis, and a quadrate liver lobectomy and cholecystectomy were performed. Large gallstones were located in the left liver lobe’s intrahepatic duct distal to the anastomosis of the intrahepatic ducts of the left medial and lateral lobes. The dilated intrahepatic duct was packed off with wet gauze, and incision and closure were performed on the most dilated section, which was proximal to the largest gallstone. After surgery, the patient showed normal liver function and was discharged with normal total bilirubin and C-reactive protein levels. On postoperative day 83, no stones were observed in the dilated common bile duct (CBD), and the degree of dilatation of the CBD had decreased from 9 mm to 4 mm, with no obstructions. Right intrahepatic gallstones were confirmed without dilatation. Hypothyroidism was managed medically. Hepatic duct incision and closure can be performed in dogs with multiple cholelithiasis. Although not the first option, intrahepatic bile duct incision proves to be a new alternative for the successful treatment of cholelithiasis in dogs. Full article

Background: Mass-forming intrahepatic cholangiocarcinoma (mICC) is the most frequent type of ICC. In contrast-enhanced computed tomography, mICC is visualized as a hypodense lesion with distal dilatation of intrahepatic bile ducts. The presented case illustrates the unusual manifestation of mICC in a 71-year-old male patient, where despite the extensive tumor mass and the hilar infiltration, the dilatation of intrahepatic bile ducts and cholestasis were not noted. Methods: A literature review on PubMed was performed. Primarily, 547 records were identified, and the titles and abstracts were systematically searched. Regarding the inclusion and exclusion criteria, 31 papers describing the non-cancerous liver lesions mimicking ICC were included in the further analysis. Results: In 41.9% of the analyzed non-cancerous lesions, the obstruction of the bile ducts was not noted, similar to our patient. A significant cholestasis has been found in 30.03% of analyzed patients. The invasion of the liver hilum was noted in one-third of the patients. Conclusions: Atypical radiological features in lesions suspected of ICC, such as the absence of intrahepatic bile-duct dilation, are common in benign lesions. In the case of radiologically atypical lesions suspected of ICC, the diagnostic imaging needs to be correlated with clinical data, and the diagnosis should be confirmed with a pathological examination. Full article