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A case of obstructive jaundice due to a pseudoaneurysm of the gastroduodenal artery is reported. This was successfully embolized, with relief of the jaundice. Relief of biliary obstruction by aneurysm embolization has not, to our knowledge, been previously described.
Pre-operative assessment of a potentially resectable peri-pancreatic mass by computed tomography (CT) is widely used, but often of limited value for lesions less than 5 cm. ERCP is frequently used to evaluate those patients with associated obstructive jaundice. To determine the clinical effectiveness of endoscopic ultrasonography (EUS), patients with pancreatobiliary lesions of less than 5 cm with or without obstructive jaundice were evaluated. CT scan, ERCP, and EUS were performed on 60 patients with a peri-pancreatic mass and/or obstructive jaundice. The results of the examinations were compared with respect to detection of an abnormality, diagnosis, and prediction of resectability. ERCP and EUS were the most sensitive and specific in detecting an abnormality of the pancreatobiliary system. The accuracy of EUS compared with the accuracy of the combination of CT scan with ERCP was significantly higher for the evaluation of the specific type and extent of pancreatobiliary disease (73% vs. 30%, p less than 0.001) and prediction of resectability (75% vs. 38%, p less than 0.05). EUS aided patient management in 75% by providing more details about the disease, and changed management in 32% by making a diagnosis or changing an incorrect diagnosis. EUS represents a significant advance in the evaluation and clinical management of pancreatobiliary disease.
Preoperative biliary drainage may improve the cytokine and acute-phase response derangements observed in patients with obstructive jaundice. We conducted a prospective longitudinal, before-after trial in our 600-bed teaching hospital. Twenty-four patients with obstructive jaundice were investigated, 11 with benign obstruction and 13 with malignant disease. Endoscopic internal biliary drainage was performed in all patients (7 by papillotomy and 17 by endoprostheses). Endotoxin, tumor necrosis factor alpha (TNF-a), interleukin-6 (IL-6), nitric oxide production, and C-reactive protein (CRP) were determined at admission and on days 2 and 7 after internal biliary drainage was accomplished. Bile cultures were obtained before and at the time of drainage. Endotoxin, IL-6, TNF-a, and CRP were significantly higher in patients with cancer. After internal drainage, endotoxin (11.4 vs. 2 EU/L; p <0.05), TNF-a (87.5 vs. 48 pg/ml; p = 0.03), and IL-6 (324 vs. 232 pg/ml; p <0.05) plasma levels decreased significantly in the early postdrainage period in patients with cancer. Endotoxin, cytokines, as well as the CRP plasma values, however, increased again on day 7 after drainage. This trend was less marked in patients with benign obstruction. Patients with positive bile cultures after drainage displayed higher levels of CRP (115 vs. 62 mg/L; p = 0.03), IL-6 (598 vs. 330 pg/ml; p = 0.04), and endotoxin (10.6 vs. 4.8 EU/L; p = 0.02) than those with negative bile cultures. Biliary tract obstruction is associated with an increase in endotoxin levels, a positive acute-phase response, and plasma cytokine elevation. After biliary drainage a transitory improvement of these alterations was observed, although values remained high 1 week postdrainage. These findings were associated with positive bile cultures.
AIM: To determine the feasibility and safety of intraluminal brachytherapy in treatment of malignant obstructive jaundice (MOJ) and to evaluate the clinical effect of intraluminal brachytherapy on stent patency and patient survival. METHODS: Thirty-four patients with MOJ were included in this study. Having biliary stent placed, all patients were classified into intraluminal brachytherapy group (group A, n = 14) and control group (group B, n = 20) according to their own choice. Intraluminal brachytherapy regimen included: HDR-192Ir was used in the therapy, fractional doses of 4-7 Gy were given every 3-6 d for 3-4 times, and standard points were established at 0.5-1.0 cm. Some patients of both groups received transcatheter arterial chemoembolization (TACE) after stent placement. RESULTS: In group A, the success rate of intraluminal brachytherapy was 98.0%, RTOG grade 1 acute radiation morbidity occurred in 3 patients, RTOG/EORTC grade 1 late radiation morbidity occurred in 1 patient. Mean stent patency of group A (12.6 mo) was significantly longer than that of group B (8.3 mo) (P<0.05). There was no significant difference in the mean survival (9.4 mo vs 6.0 mo) between the two groups. CONCLUSION: HDR-192Ir intraluminal brachytherapy is a safe palliative therapy in treating MOJ, and it may prolong stent patency and has the potentiality of extending survival of patients with MOJ.
OBJECTIVE: To estimate the operative mortality in patients with malignant obstructive jaundice. METHODS: Twelve risk factors were analyzed using multivariate discriminant analysis in 90 patients who had been operated on. RESULTS: Operative mortality was significantly related to the following factors: age, duration of jaundice, packed RBC volume, white blood cell count and concentration of blood urine nitrogen; it was not significantly related to diseases and types of operation. The following formula was obtained: packed RBC volume x 0.09954-age x 0.04018- blood urine nitrogen x 0.23693-duration of jaundice x 2.07388-WBC count x 0.21118+ 5.26593. With this formula, an operative mortality of 77.8% was predicted. CONCLUSION: With a positive value from the formula, the patient should be operated on; otherwise non-operative treatment is advocated.
We report a 32-year-old man with acute myeloid leukemia presenting as obstructive jaundice. Imaging revealed dilated common bile duct with abrupt narrowing at the lower end, distended gall bladder, and dilated intrahepatic biliary radicles. In addition he had a mass lesion in the urinary bladder. On evaluation he was found to have the eosinophilic variant of M4 subtype acute myeloid leukemia. He expired before chemotherapy could be instituted.
In the differential diagnosis of pancreatic cancer, CA19-9 appears to be the most sensitive and specific marker currently in use. In the absence of jaundice and at levels greater than 1000 U/ml, the specificity is almost 100%. Levels higher than 1000 U/ml are very uncommon for benign diseases. We report a case of obstructive jaundice due to an impacted stone in the common bile duct with cholangitis, where a CA19-9 level of 61,800 U/ml prompted suspicion of a malignant cause. After treatment the CA19-9 returned to a normal level. One year postoperatively neither abdominal ultrasound nor CT-scan showed any sign of intraabdominal malignancy. Reviewing the literature, we conclude that even very high levels of CA19-9 in cases with obstructive jaundice can be caused by benign diseases. Unlike other tumour markers (alpha-foetoprotein, carcinoembryonic antigen), where exceedingly high levels are definitely caused by malignancy, high levels of CA19-9 can be caused by benign obstructive jaundice. In such cases CA19-9 is useless as a tumour marker. The biliary obstruction must be treated successfully and more diagnostic procedures or even laparotomy performed, to exclude malignancy or treat a benign disease.
Decreased serum uric acid levels resulting from renal urate wasting have been occasionally encountered in jaundiced patients. However, in these cases, there are no data concerning the underlying renal tubular defects. In the present study, we investigated the renal tubular function in 35 patients with obstructive jaundice of various severity and causes (11 with lithiasis, 17 with carcinoma, and 7 with intrahepatic cholestasis). A detailed study of the renal tubular function was performed. Beyond the conventional methods, (1)H-NMR spectroscopy of urine was used to evaluate noninvasively renal damage by the characteristic perturbation in the excretion pattern of low-molecular weight endogenous metabolites. On admission, patients with obstructive jaundice had significantly lower serum uric acid and phosphate levels and higher bile acid concentrations compared with 40 age- and sex-matched controls. Serum uric acid levels presented a negative correlation with the total and direct bilirubin as well as the fractional excretion of uric acid. Furthermore, a great number of the patients studied developed one or more proximal tubular dysfunction manifestations beyond uricosuria, such as renal glucosuria, phosphaturia, and increased excretion of alpha(1)-microglobulin. (1)H-NMR spectroscopy of the urine showed decreased levels of citrate and hippurate and increased levels of 3-hydroxybutyrate and acetate. In 12 patients partial or complete remission of jaundice was followed by an improvement of the proximal renal tubular damage. In conclusion, obstructive jaundice can cause a partially reversible generalized proximal tubular dysfunction.
Inflammatory pseudotumours are rare benign tumours characterized by an inflammatory process and can occur in any system. We present a case of inflammatory pseudotumours of the liver presenting with obstructive jaundice due to a mass forming lesion in the left lobe of the liver which was treated by left hepatic lobectomy. Inflammatory pseudotumour of the liver is a benign lesion and diagnosis with an image examination is difficult. Surgical management depends on the location of the lesion. Peripheral hepatic pseudotumours may be treated with simple observation or conservative therapy. In contrast to this, those involving the porta hepatis require treatment for obstructive jaundice.
Inflammatory myofibroblastic tumour is a rare entity in children with few reported series. The extrahepatic bile duct is an unusual location for this tumour. The authors report here the case of an 8-year-old girl presenting with obstructive jaundice due to inflammatory myofibroblastic tumour of the extrahepatic bile ducts with differential diagnosis of obstructive jaundice in children.
Three types of expandable metallic stents were used to relieve obstructive jaundice in 59 patients. They consisted of 3 cases with benign stricture, and 56 with malignant obstruction including 28 of cholangiocarcinoma, 17 of pancreatic carcinoma, 9 of lymph node metastases, and 2 of gall bladder carcinoma. The median age of patients was 68.9 years. Of 56 cases with malignant obstruction, 51 cases were able to remove external drainage catheter. In these 51 cases, 35 patients died, and 16 are still alive. No significant difference was noted in the incidence of stent destruction or migration in three types of stents. The average survival period was 189.9 days in 35 patients who died after withdrawal of external drainage. Twenty-three of 35 patients had no recurrence of obstructive jaundice. Sixteen patients with malignant obstruction are still alive and have been observed for 22 to 764 days. The 30 day mortality rate was 6.8%. Three cases of acute cholecystitis were noted after procedure. It is warranted to say that endoprostheses using expandable metallic stents will be the major treatment of choice for biliary obstruction because of long term patency and low complication rate.
We report a rare case of obstructive jaundice caused by an intrapancreatic hydatid cyst in a 17-year-old black girl. Ultrasonography and computed tomography demonstrated the obstructing cyst in the head of the pancreas. Cyst aspiration produced clear fluid with a low amylase content and no hydatid hooklets or protoscolices. Pancreaticoduodenectomy was performed for a presumed cystic neoplasm of the pancreas, but histology showed the true diagnosis. Pancreatic hydatidosis should be considered in the differential diagnosis of obstructing pancreatic cysts in the appropriate epidemiological setting.
BACKGROUND/AIMS: To investigate the susceptibility of kidneys to ischemia-reperfusion injury under obstructive jaundice. MATERIALS AND METHODS: Bile ducts of male rats were ligated for five days, right kidneys were removed, and vascular clamps were placed across left renal arteries for 30 minutes. RESULTS: Twenty-four hours later, ischemia-reperfusion produced renal injury in jaundiced rats as shown by increased serum creatinine and urea nitrogen levels. Histological observation showed tubular damages. These changes were minimal after ischemia-reperfusion in control rats. Renal thiobarbituric acid reactive substance contents were increased after bile duct ligation, which did not change after ischemia-reperfusion. On the other hand, ischemia-reperfusion produced a significant increase in renal thiobarbituric acid reactive substance contents in control rats. Renal glutathione contents were increased two fold after bile duct ligation and they were significantly decreased by ischemia-reperfusion. CONCLUSIONS: Kidneys in obstructive jaundice appear to be susceptible to ischemia-reperfusion injury. Although protective roles of GSH is suggested, the role of oxygen radicals in this type of renal injury remains to be further elucidated.
BACKGROUND: Cysteinyl leukotrienes (LTs) are potent proinflammatory mediators. They are predominantly excreted from blood by hepatobiliary elimination. To explore the clinical significance of biliary cysteinyl LTs, we determined their concentration changes in bile during treatment in patients with obstructive jaundice. METHODS: Bile samples were obtained during endoscopic or transhepatic biliary drainage. Leukotrienes C(4), D(4), and E(4) were quantified by two-step reversed-phase high-performance liquid chromatography and subsequent radioimmunoassay. RESULTS: The increased excretion of cysteinyl LTs (LTC(4) + LTD(4) + LTE(4)) decreased between day 1 and 14 after drainage (means, 171 pmol/h to 79 pmol/h; P < 0.02). During drainage, the excretion was higher when there was additional cholangitis (mean, 225 and 86 pmol/h, with and without cholangitis, respectively; P < 0.001). The concentrations of LTD(4) and LTE(4) were also higher with additional cholangitis than without (LTD(4), mean 6.0 vs 2.0 nM; P < 0.05; LTE(4), 6.8 vs 2.4 nM; P < 0.02, respectively). Biliary LTC(4) was detected only in patients with cholangitis. The biliary excretion of cysteinyl LTs was positively correlated with leukocyte concentration ( r = 0.68; P < 0.005) and C-reactive protein ( r = 0.73; P < 0.005) in blood. Furthermore, only in the absence of cholangitis, the excretion was positively correlated with serum gamma-glutamyl transferase ( r = 0.76; P < 0.02) and alanine aminotransferase ( r = 0.72; P < 0.02). CONCLUSIONS: The excretion of biliary cysteinyl LTs increases with the severity of cholestasis and hepatic inflammation in patients with obstructive jaundice. An additional increase of cysteinyl LTs was observed during bacterial cholangitis. The increased biliary excretion of biologically active cysteinyl LTs may contribute to the aggravation of cholestasis and inflammatory reaction in obstructive jaundice.
The authors report a patient with obstructive jaundice as the first clinical manifestation of a primary malignant melanoma metastatic in the ampulla of Vater. After the histologic diagnosis of the metastases was made, the primary tumor was located in the skin of the back. Obstruction jaundice secondary to ampullary obstruction due to metastatic melanoma has only been reported twice, and in neither case was jaundice the first symptom of the disease.
To determine the impact and use of alternative treatment methods of draining malignant obstructive jaundice, a review of 41 patients who were managed by a surgical hepatobiliary service, in which non-surgical (endoscopic and radiological) treatment modalities were available equally, was performed. Of the 41 patients, 39 patients experienced 45 attempted treatments with ultimate success in 35 (90%) patients. The non-operative management of the high-risk patients did not result in a higher mortality at 9% and 25% for endoscopic and radiological management, respectively, than that of 15% which was achieved in the operative series. As a result of treatment selection, the non-operative groups survived for a shorter time (eight weeks) than did those who underwent operation (survival, 30 weeks). This shorter survival time resulted in a similar readmission rate for the non-operative and operative groups; patients did not survive long enough in the non-operative group to develop stent complications. Even if surgery is the chosen treatment modality, preoperative endoscopic retrograde cholangiopancreatography is recommended in planning that surgery. We conclude that in patients with malignant obstructive jaundice, surgical treatment has the advantage of fewer late complications, while non-surgical treatment has the advantage of less initial morbidity or mortality. If the aim is to optimize palliation not only in the short term, but also in the longer term, then the selection of patients for treatment on the basis of pretreatment imaging results, the operative risk and the predicted duration of survival, will result in operative and non-operative methods of treatment being used approximately equally.
BACKGROUND AND AIMS: The role of Kupffer cells in obstructive jaundice (OJ) has not been fully understood. The aims of the present study were to measure superoxide and nitric oxide (NO) production by Kupffer cells in experimental OJ in rats and to investigate the response to internal and external biliary drainage. METHODS: Eighty male Sprague-Dawley rats were assigned to four groups: sham operation, OJ, and internal and external biliary drainage. Kupffer cells were isolated on day 7 in the sham operation and OJ group, and on day 7 after drainage procedures. Cells were cultured with or without lipopolysaccharide (LPS). Superoxide production was quantified in cultured Kupffer cells at 2 h and 48 h, respectively, after cell isolation using the superoxide dismutase inhibitable ferricytochrome c reduction method. Nitrite production in cell culture supernatants was measured 48 h later using Greiss reagents. RESULTS: Without LPS stimulation, Kupffer cells produced comparable superoxide and nitrite in each group (P > 0.05). With LPS stimulation, Kupffer cells in the OJ group produced significantly higher superoxide anions than the other groups (P = 0.006). Nitrite production was significantly increased in the OJ group and external biliary drainage group compared to rats in the sham operation and internal drainage groups (P < 0.01). CONCLUSIONS: Kupffer cells from rats with OJ produce great amounts of endotoxin-mediated oxidants. Both internal and external biliary drainage can decrease the elevated superoxide production. Internal drainage is superior to external drainage for reversing the distortional capacity of NO production by Kupffer cells.
OBJECTIVE: To review the effectiveness of preoperative biliary drainage (PBD) in patients with obstructive jaundice resulting from tumors. SUMMARY BACKGROUND DATA: This was a systematic review, including a meta-analysis, of randomized controlled trials and comparative cohort studies conducted worldwide and published between 1966 and September 2001, classified on methodologic strength and subdivided into level 1 (randomized controlled trials) and level 2 (comparative cohort studies). METHODS: Comparison was made of PBD versus no PBD in jaundiced patients undergoing resection of a tumor. Outcome measures were in-hospital death rate, overall complications resulting from the treatment modality (drainage- and surgery-related complications), and hospital stay. Effect sizes were calculated and combined in meta-analyses. Relative differences (%) were calculated to compare effects on outcome measures. RESULTS: Five randomized controlled studies comprising 302 patients met the inclusion criteria for level 1 studies, and 18 cohort studies comprising 2,853 patients met the criteria for level 2 studies. Meta-analysis of level 1 studies showed no difference in the overall death rate between patients who had PBD and those who had surgery without PBD. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. At level 2, there was no difference in the death rate between the two treatment modalities. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. If PBD had been without complications, then complications would be in favor of drainage based on level 1 studies, and no difference based on level 2 studies. Further, PBD was not able to reduce the length of postoperative hospital stay compared with surgery without PBD; instead, it prolonged the stay. CONCLUSIONS: This meta-analysis shows that PBD with current standards for patients with obstructive jaundice resulting from tumors carries no benefit and should not be performed routinely. The potential benefit of PBD in terms of postoperative rates of death and complications does not outweigh the disadvantage of the drainage procedure. Only if PBD-related complications could be reduced by 27% and consequently diminish hospital stay could PBD be beneficial. Further randomized controlled trials with improved PBD techniques are necessary.