A child with a post-tramatic pancreatic pseuodocyst developed pancreatic fistula, following percutaneous drainage of the cyst. The fistula output was about 120ml/day and lasted for a month. A diagnostic ERCP revealed main pancreatic duct disruption. The fistula output ceased over the next two days following the ERCP. The patient has been well for the past four years. This patient's immediate recovery after ERCP could possibly be due to dislodgement of a mucus plug by the contrast injected during ERCP. Such a mechanism can explain the previous sporadic reports of spontaneous cure of persistent pancreatic fistulae in children.
Pancreatic cancer is notoriously difficult to diagnose until a late stage when curative options are no longer available. Owing to its relatively low incidence and the lack of sensitivity of current diagnostic tool, screening of pancreatic cancer in the general population is not recommended. However, in high-risk individuals, especially those with well-described genetic syndromes and a strong family history of pancreatic cancer, screening can be carried out. Detection of a lesion of the diameter
To investigate the anxieties of patients undergoing oesophago-gastro-duodenoscopy (OGD), colonoscopy and endoscopic retrograde cholangio-pancreatography (ERCP) in relation to their demographic features, their knowledge and understanding of the procedure, its indication, and their doctors' explanation. A standard questionnaire was filled in consecutively for 280 OGD patients, 64 colonoscopy patients and 50 ERCP patients.
Ascaris lumbricoides infection usually results in mild gastrointestinal symptoms. However, heavy worm load infections can cause major complications. In one-third of the latter cases, the worms enter the bile duct causing cholangitis, biliary colic and acute pancreatitis. We describe an eleven-year-old Indian boy who presented with high grade fever, vomiting of worms, jaundice and right hypochondria! pain. Examination revealed an ill, malnourished and jaundiced child. His abdomen was tender with positive Murphy's sign and hepatomegaly. Urgent ultrasound showed hepatomegaly with dilated intrahepatic and common bile ducts (CBD). There were tubular echogenic filling defects with central sonolucency along the long axis of the CBD. He was fasted, started on intravenous fluids and broad spectrum antibiotics. As there was no improvement after 24 hours, endoscopic retrograde cholangio-pancreaticography (ERCP) was performed: it showed worms in the CBD. A stent was inserted to decompress the bile ducts and to ensure biliary drainage. The patient improved, the fever settled, jaundice resolved, serum amylase and transaminase levels normalised. It was planned to remove the stent at a later date.
This report highlights the association of a tumour in an acalculous gall bladder with an anomalous pancreatico-biliary junction (PBJ) and a type IVa choledochal cyst. Cholecystectomy and Rouxen-Y hepatico-jejunostomy (RHJ) was performed after division of the common bile duct (CBD) and excision of the dilated segment. The details of the case are presented and the role of an abnormal PBJ in gall bladder carcinogenesis is discussed.
WHO declared worldwide outbreak of COVID-19 a pandemic on 11 March 2020. Healthcare authorities have temporarily stopped all elective surgical and endoscopy procedures. Nevertheless, there is a subset of patients who require emergency treatment such as aerosol-generating procedures. Herein, we would like to discuss the management of a patient diagnosed with impending biliary sepsis during COVID-19 outbreak. The highlight of the discussion is mainly concerning the advantages of concurrent use of aerosol protective barrier in addition to personal protective equipment practice, necessary precautions to be taken during endoscopy retrograde cholangiopancreatography and handling of the patient preprocedure and postprocedure.
This is a case report of ascaris worm in the common bile duct in a 61 year old lady. Ultrasound diagnosis was initially made based on the presence of linear hyperreflective foci within the common bile duct. ERCP confirmed a single worm within the duct. Balloon extraction was then successfully carried out following papillotomy. This case illustrates the value of ultrasound in the definitive diagnosis of biliary ascariasis and the therapeutic role of ERCP.
A 64-year-old lady presented with a brief history of abdominal pain associated with obstructive jaundice. Endoscopic retrograde cholangiopancreaticography (ERCP) revealed a short segment stricture with contact bleeding and the brush cytology confirmed presence atypical cells. Ca 19.9 levels were markedly elevated. She was planned for a Whipple’s procedure but was instead subjected to a total pancreatectomy based on intraoperative findings of a diffusely hard and nodular pancreas. Histopathological examination confirmed our diagnosis of diffuse pancreatic adenocarcinoma. This rare presentation of a locally contained and fully resectable diffuse pancreatic adenocarcinoma is being discussed.
Acute pancreatitis is one of the common reasons for surgical admission. It is a potentially lethal disease that is increasing in its incidence. The most common causes of acute pancreatitis is from gallstones and alcohol. Other causes of acute pancreatitis include hypertriglyceridaemia, hyperparathyroidism, pancreatic malignancy, Endoscopic retrograde cholangiopancreatography (ERCP), trauma, infectious agents, drugs, autoimmunity, and hereditary. The treatment of acute pancreatitis is mainly supportive. The complication of ERCP in acute pancreatitis can be divided into local complication (pancreatic abscess, pseudocyst), systemic complications (renal failure, respiratory failure, cardiogenic shock) and biliary sepsis (acute cholangitis and acute cholecystitis). However, early ERCP and possible sphincterotomy should be kept in mind for patients with severe disease and biliary obstruction who are not improving with medical therapy. This study is done to compare the complication rate of ERCP and conservative management in acute pancreatitis for past 6 years in Pusat Perubatan UKM.
Opium addicts (OA) with no biliary symptoms have been shown to have dilated common bile duct (CBD). Endoscopic retrograde cholangio-pancreatography (ERCP) without biliary drainage in such asymptomatic OA is hazardous. Hence it is not indicated unless there are clear clinical and laboratory evidences of biliary stasis.
Coronavirus disease 2019 (COVID-19) is a highly contagious, severe acute respiratory syndrome that poses significant health risks to healthcare providers. A delicate balance is needed between timely intervention for ill patients without apparent COVID-19 infection and the safety of healthcare personnel who provide essential treatment in the midst of the pandemic. We report our experience managing a 70-year-old man who presented with acute gallstone pancreatitis at our hospital during the COVID-19 outbreak in Malaysia. We also describe the safety protocol measures that have been implemented in our institution to protect the healthcare personnel from this disease during endoscopic retrograde cholangiopancreatography. This case illustrates the importance of meticulous planning, risk assessment, effective team communication and strict adherence to recommendations when providing treatment during an unprecedented pandemic.
We report three cases of Mirizzi syndrome, two with external compression of the common hepatic duct and another with cystobiliary fistula. All patients presented with jaundice. The diagnosis was suggested by ultrasonography and confirmed by endoscopic retrograde cholangiography (ERC). All three had the stones removed surgically, one through a choledochotomy, another through an opening in the gall bladder and the third at the time of subtotal cholecystectomy. We would like to propose a simple classification of Mirizzi syndrome, based on surgical procedures necessary for the correction of the pathological anatomy. If it involves the removal of calculi with some form of cholecystectomy, we consider it as Type I, whereas Type II involves the construction of a hepaticojejunostomy apart from the removal of calculi.
ERCP (Endoscopic Retrograde Cholangiopancreaticography) was introduced in this hospital in late 1995. Since then, a lot of improvement have been achieved in the management of biliary tract diseases. Various general surgeons posted to this hospital have been trained in this procedure. A study was done to include all patients admitted for ERCP from August 1998 to July 1999. A total of 322 new patients with a mean of 26.9 cases a month had underwent this procedure. The duration of cannulation varied from 2 minutes to 45 minutes with a mean of 12 minutes. Cannulation rate by various surgeons differed. Overall success rate was 80%. Mortality was 0.6 % and morbidity was 0.9%. ERCP is safe and it takes at least 6 months of regular duodenoscopy before one can master the technique. Achieving 80% cannulation rate, has definitely reduced unnecessary common bile duct (CBD) explorations. During this study we have trained various surgeons in this procedure and at least 2 surgeons could be credentialled according to the guidelines provided by the Malaysian Society of Gastroenterology and Hepatology. During this study we have identified various reasons for the failure of cannulation which are useful for future training of endoscopists.
Anomalous pancreatico-biliary junction (APBJ) is commonly associated with cystic dilatation of the bile ducts but recently, several cases without the cystic dilatation have been reported. We treated a young female patient with intractable back and epigastric pain of three months duration. The spine was normal on magnetic resonance imaging (MRI), but several lymph nodes were seen around the coeliac axis. An APBJ, a non-cystic biliary system, non-filling of the gallbladder and an irregular right margin of the bile duct were evident on endoscopic retrograde pancreatography (ERCP), which was highly suggestive of gallbladder (GB) malignancy. At surgery, the GB was hard with local infiltration of the bile duct. Numerous large para-aortic and supraduodenal lymph nodes were present and only a biopsy was possible. Details of the case are presented and the growing etiological importance of an APBJ, especially without cystic biliary dilatation in gallbladder carcinogenesis is discussed.