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Semash KO. Post-liver transplant biliary complications. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2024; 26:72-90. [DOI: 10.15825/1995-1191-2024-3-72-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
Biliary complications (BCs) are the most frequent complications following liver transplantation (LT). They are a major source of morbidity after LT. The incidence of BCs after LT is reported to range from 5% to 45%. The main post-LT biliary complications are strictures, biliary fistulas and bilomas, cholelithiasis, sphincter of Oddi dysfunction, hemobilia, and mucocele. Risk factors for biliary complications are diverse. In this article we seek to review the main types of biliary complications and modern approaches to their diagnosis and treatment.
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2
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Matsubayashi H, Todaka A, Ishiwatari H, Sato J, Niiya F, Kondo T, Ono H, Yamazaki K, Sasaki K, Kiyozumi Y. Discordant microsatellite instability findings in two samples from a patient with biliary cancer that responded to pembrolizumab. Clin J Gastroenterol 2023; 16:748-754. [PMID: 37490248 DOI: 10.1007/s12328-023-01833-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023]
Abstract
Microsatellite instability (MSI) is a key marker to predict response to immune checkpoint inhibitors; however, only 1-2% of biliary cancers have this genomic feature. In a patient with hilar biliary cancer, MSI was examined in two cancer specimens (forceps biopsy from the biliary stricture and endoscopic ultrasound-guided fine-needle aspiration biopsy [EUS-FNAB] from the adjacent lymph node). We observed discordant results, as high frequency of MSI was found only in the forceps biopsy. Although the FNAB sample was 10 times larger than that of the forceps biopsy, the tumor concentration was much lower, which is a possible reason for the discordance. Besides, immunohistochemistry of four mismatch-repair (MMR) proteins showed proficient MMR expressions. The tumor became refractory to gemcitabine, cisplatin, and S-1 but responded well to pembrolizumab. Caution is needed for sample selection and for interpretation of the test's results, to avoid missing rare chance for effective molecular target agents.
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Affiliation(s)
- Hiroyuki Matsubayashi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan.
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Akiko Todaka
- Division Gastrointestinal Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Fumitaka Niiya
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Toshikazu Kondo
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kentaro Yamazaki
- Division Gastrointestinal Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoshimi Kiyozumi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
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3
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Matsubayashi H, Sasaki K, Ono S, Ishiwatari H, Ishikawa K, Satoh T, Kimura H, Kakushima N, Yoshida M, Yabuuchi Y, Kishida Y, Imai K, Sugiura T, Ono H. Efficacy of endoscopic samplings during initial biliary drainage for cases of pancreatic head cancer: United diagnostic yields of multiple pathological samplings. Pancreatology 2021; 21:1548-1554. [PMID: 34607772 DOI: 10.1016/j.pan.2021.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/21/2021] [Accepted: 09/25/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The diagnostic ability of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been fully studied; however, the efficacy of other endoscopic samplings (OESs) is less clear. The aim of this study was to examine the diagnostic efficacies of OESs for pancreatic head cancer (PHC). METHODS The diagnostic efficacies of endoscopic samplings were retrospectively analyzed in 448 PHC cases and 63 cases of mass-forming pancreatitis (MFP) during initial transpapillary biliary drainage. The OESs included duodenal biopsy (118 PHCs and 50 MFPs), biliary biopsy (218 and 51) with cytology (368 and 53), and pancreatic duct biopsy (23 and 13) with cytology (56 and 43). EUS-FNA was conducted in a different session (149 and 62). Factors associated with OES sensitivity were analyzed. The sensitivity of biliary biopsy was compared between 1.95 mm and 1.8 mm forceps. RESULTS Cancer cells were confirmed in 87.9% of the EUS-FNA samplings and in 64.1% (268/418) obtained by combined OESs (average 1.7 OES types per case): 68.6% by duodenal biopsy, 59.6% by biliary biopsy, 32.6% by biliary cytology, 73.9% by pancreatic duct biopsy, and 33.9% by pancreatic duct cytology. No MFP cases revealed cancer by any sampling. OESs did not increase adverse events. Duodenal stenosis, serum bilirubin, tumor size, and pancreatic juice amounts were associated with OES sensitivity. Biliary biopsy had the same sensitivity with different forceps. CONCLUSION EUS-FNA was the most diagnostic protocol; however, OESs can be safely applied during the initial biliary drainage to reduce the demand for EUS-FNA while providing good diagnostic yields.
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Affiliation(s)
- Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan; Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan.
| | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Sachiyo Ono
- Division of Pathology, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Hirotoshi Ishiwatari
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Kazuma Ishikawa
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Tatsunori Satoh
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Hidenori Kimura
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Yoshihiro Kishida
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Teichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan
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4
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Nakamura J, Takasumi M, Hashimoto M, Kato T, Kobashi R, Hikichi T, Ohira H. The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding. Intern Med 2021; 60:883-889. [PMID: 33087676 PMCID: PMC8024959 DOI: 10.2169/internalmedicine.6018-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Bilio-duodenal bleeding, such as post-endoscopic sphincterotomy (EST) bleeding, common bile duct (CBD) bleeding after endoscopic retrograde cholangiopancreatography (ERCP), and duodenal bleeding due to malignant tumour invasion, can sometimes become severe. Six cases of refractory bilio-duodenal bleeding were stanched via covered self-expandable metallic stent (CSEMS) insertion, even though three of the patients had a history of gastrectomy. The dumbbell-shaped CSEMS was useful for managing post-EST bleeding. Additional duodenal CSEMS insertion was useful for the patient who had previously undergone uncovered SEMS insertion, and no migration of the CSEMS was observed. CSEMS insertion was useful for treating refractory bilio-duodenal haemorrhaging.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Rei Suzuki
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Naoki Konno
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Yuki Sato
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Hiroki Irie
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Jun Nakamura
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Mika Takasumi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Tsunetaka Kato
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Ryoichiro Kobashi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Japan
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5
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Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J Hepatol 2021; 13:66-79. [PMID: 33584987 PMCID: PMC7856868 DOI: 10.4254/wjh.v13.i1.66] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/01/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors. Despite the remarkable advances in the surgical techniques and immunosuppressive therapy, the postoperative morbidity and mortality still remain high and the leading causes are biliary complications, which affect up to one quarter of recipients. The most common biliary complications are anastomotic and non-anastomotic biliary strictures, leaks, bile duct stones, sludge and casts. Despite the absence of a recommended treatment algorithm many options are available, such as surgery, percutaneous techniques and interventional endoscopy. In the last few years, endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches. Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed. Recently, new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures. Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment. Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases. This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.
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Affiliation(s)
- Irina Boeva
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Petko Ivanov Karagyozov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Ivan Tishkov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
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6
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Tien T, Tan YC, Baptiste P, Tanwar S. Haemobilia in a previously stented hilar cholangiocarcinoma: successful haemostasis after the insertion of fcSEMS. Oxf Med Case Reports 2020; 2020:omaa010. [PMID: 32128221 PMCID: PMC7048067 DOI: 10.1093/omcr/omaa010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/14/2020] [Accepted: 01/25/2020] [Indexed: 12/23/2022] Open
Abstract
Haemobilia describes blood loss from the biliary tract and classically presents as Quincke's triad: upper gastrointestinal bleeding (UGIB), jaundice and right upper quadrant abdominal pain. We discuss the case of a 70-year-old male with a previously stented Bismuth 1 hilar cholangiocarcinoma who presented with haematemesis. He had a similar presentation a month ago where a forward viewing gastroscope identified fresh and altered blood in the distal stomach but no clear source of bleeding. During this admission, a side-viewing duodenoscope identified bleeding from the periampullary region, which was managed by inserting a fully covered self-expanding metal stent (fcSEMS) within his pre-existing uncovered SEMS to tamponade the haemorrhage. This case highlights the importance of using a side-viewing duodenoscope for patients with UGIB on a background of a stented cholangiocarcinoma and inserting a fcSEMS within an uncovered SEMS is feasible and effective in managing these patients.
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Affiliation(s)
- T Tien
- Department of Gastroenterology, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Y C Tan
- Department of Gastroenterology, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - P Baptiste
- General Practice, NHS Waltham Forest Clinical Commissioning Group, London, UK
| | - S Tanwar
- Department of Gastroenterology, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
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7
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Lou J, Hu Q, Ma T, Chen W, Wang J, Pankaj P. A novel approach with holmium laser ablation for endoscopic management of intrahepatic biliary stricture. BMC Gastroenterol 2019; 19:172. [PMID: 31675911 PMCID: PMC6824045 DOI: 10.1186/s12876-019-1093-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 10/14/2019] [Indexed: 12/27/2022] Open
Abstract
Background Hepatolithiasis, featuring high incidence, severe symptoms, and common recurrence, poses a heavy disease burden. Endoscopic management provides an opportunity to cure hepatolithiasis, but fails to properly resolve biliary stricture without additional interventional techniques. An innovative approach towards endoscopic management of biliary stricture is required. Methods Holmium laser ablation was applied to biliary strictures via endoscopic access. Patients’ demographic, operative, and follow-up data after receiving holmium laser ablation were retrospectively collected for analysis. Results A total of 15 patients (4 males and 11 females) underwent stricture ablation by holmium laser via cholangioscopy. All the patients successfully received holmium laser ablation, indicating a technical success rate of 100%. No postoperative mortality or no major perioperative complication was observed. During the follow-up period, the recurrence-free rate was 73% at 2 years and 67% at 5 years. Conclusions We successfully developed a novel technique of biliary stricture removal by cholangioscopic holmium laser ablation with satisfying clinical outcomes.
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Affiliation(s)
- Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, Zhejiang, China.
| | - Qida Hu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, Hangzhou, 310003, Zhejiang, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, Hangzhou, 310003, Zhejiang, China
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, Hangzhou, 310003, Zhejiang, China
| | - Ji Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, Hangzhou, 310003, Zhejiang, China
| | - Prasoon Pankaj
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, Zhejiang, China
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8
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Zhornitskiy A, Berry R, Han JY, Tabibian JH. Hemobilia: Historical overview, clinical update, and current practices. Liver Int 2019; 39:1378-1388. [PMID: 30932305 DOI: 10.1111/liv.14111] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/16/2022]
Abstract
Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosis of hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.
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Affiliation(s)
- Alex Zhornitskiy
- Department of Internal Medicine, UCLA-Olive View Medical Center, Sylmar, California
| | - Rani Berry
- Department of Internal Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - James Y Han
- Department of Internal Medicine, University of California, Irvine, California
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California
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9
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Satoh T, Matsubayashi H, Ishiwatari H, Fujie S, Kaneko J, Sato J, Ito S, Kishida Y, Imai K, Hotta K, Yoshida M, Kawata N, Takizawa K, Kakushima N, Sawada A, Ono H. Rupture of Pseudoaneurysm after Biliary Metallic Stent Placement. Intern Med 2019; 58:1453-1457. [PMID: 30626807 PMCID: PMC6548938 DOI: 10.2169/internalmedicine.1862-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Rupture of a pseudoaneurysm (PA) has been reported as a rare but serious adverse event associated with endoscopic biliary stenting. We herein report 2 cases of severe biliary bleeding from a PA that developed 10-14 days after placement of a self-expandable metallic stent (SEMS) for biliary malignancy. The first patient was successfully embolized with endovascular coiling. However, the second patient had wide-spreading cholangiocarcinoma and, despite being treated once by full coiling, developed a second rupture of PA two months after starting systemic chemotherapy. Clinicians should be aware of the possibility of PA and carefully follow stented patients after endovascular treatment.
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Affiliation(s)
| | | | | | - Shinya Fujie
- Division of Endoscopy, Shizuoka Cancer Center, Japan
| | | | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Japan
| | | | | | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Japan
| | | | | | | | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Japan
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10
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Tsai MC, Wang CC, Wang YT, Yang TW, Chen HY, Tseng MH, Lin CC. Major bleeding risk of endoscopic sphincterotomy versus endoscopic papillary balloon dilatation in hemodialysis patients. Saudi J Gastroenterol 2019; 25:106-112. [PMID: 30479319 PMCID: PMC6457181 DOI: 10.4103/sjg.sjg_246_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilatation (EPBD) are used for therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The postprocedure bleeding rate for EPBD is low in the normal population; however, this bleeding rate in a group of patients prone to bleeding, such as patients with end-stage renal disease, is not well-established. We therefore evaluated the post-EST and post-EPBD bleeding rate among hemodialysis (HD) patients based on data from Taiwan's National Health Insurance Research Database (NHIRD). PATIENTS AND METHODS The NHIRD entries for a population of 2 million were screened for patients who had a catastrophic illness card for HD between 1st January 2004 and 31st December 2011 and these patients were enrolled as research subjects. The rates of major gastrointestinal tract bleeding events appearing within 14 days after EST or EPBD were compared between HD and non-HD patients. RESULTS A total of 3561 patients, over 18 years of age and without liver cirrhosis or hematologic diseases, underwent 3826 EST and 280 EPBD procedures during the 8 calendar years selected for our analysis. The total post-ERCP major bleeding rate was much higher in HD than in non-HD patients (8.64% vs. 2.16%, P < 0.0001). The rate of postprocedure major bleeding events was lower for non-HD patients who underwent EPBD than those who underwent EST (0.75% vs. 2.26%; P = 0.049), whereas the postprocedure major bleeding event rates were similar in HD patients who underwent either EPBD or EST (8.70% vs. 8.33%; P = 0.484). CONCLUSION Post-ERCP, post-EST, and post-EPBD major bleeding rates were all higher in HD patients in this study. EPBD resulted in lower postprocedure major bleeding events than EST in the non-HD population, but it failed to provide the reduction in bleeding events needed to perform endoscopic hemostasis in HD patients.
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Affiliation(s)
- Ming-Chang Tsai
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chi-Chih Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yao-Tung Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tzu-Wei Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan,Department of Biological Science and Technology, Institute of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Hsuan-Yi Chen
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ming-Hseng Tseng
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan,Information Technology Office, Chung Shan Medical University Hospital, Taichung, Taiwan,Address for correspondence: Prof. Chun-Che Lin, School of Medicine, Chung Shan Medical University, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1, Jianguo N. Rd., South Dist., Taichung City 402, Taiwan. E-mail: Prof. Ming-Hseng Tseng, Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan. E-mail:
| | - Chun-Che Lin
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan,Address for correspondence: Prof. Chun-Che Lin, School of Medicine, Chung Shan Medical University, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1, Jianguo N. Rd., South Dist., Taichung City 402, Taiwan. E-mail: Prof. Ming-Hseng Tseng, Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan. E-mail:
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11
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Berry R, Han JY, Kardashian AA, LaRusso NF, Tabibian JH. Hemobilia: Etiology, diagnosis, and treatment ☆. LIVER RESEARCH 2018; 2:200-208. [PMID: 31308984 PMCID: PMC6629429 DOI: 10.1016/j.livres.2018.09.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon but important cause of gastrointestinal hemorrhage. Reports of hemobilia date back to the 1600s, but due to its relative rarity and challenges in diagnosis, only in recent decades has hemobilia been more critically studied. The majority of cases of hemobilia are iatrogenic and caused by invasive procedures involving the liver, pancreas, bile ducts and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other leading causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described (i.e. Quincke's triad), but this is present in only 25%-30% of patients with hemobilia. Therefore, prompt diagnosis depends critically on having a high index of suspicion, which may be based on a patient's clinical presentation and having recently undergone (peri-) biliary instrumentation or other predisposing factors. The treatment of hemobilia depends on its severity and suspected source and ranges from supportive care to advanced endoscopic, interventional radiologic, or surgical intervention. Here we provide a clinical overview and update regarding the etiology, diagnosis, and treatment of hemobilia geared for specialists and subspecialists alike.
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Affiliation(s)
- Rani Berry
- Department of Internal Medicine, UCLA Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - James Y. Han
- Department of Internal Medicine, University of California Irvine, Irvine, CA, USA
| | - Ani A. Kardashian
- UCLA Gastroenterology Fellowship Training Program, Vatche and Tamar Manoukian Division of Digestive Diseases, Los Angeles, CA, USA
| | - Nicholas F. LaRusso
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA,Corresponding author. Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA., (J. H. Tabibian)
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Berry R, Han J, Girotra M, Tabibian JH. Hemobilia: Perspective and Role of the Advanced Endoscopist. Gastroenterol Res Pract 2018; 2018:3670739. [PMID: 30116262 PMCID: PMC6079575 DOI: 10.1155/2018/3670739] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/23/2018] [Indexed: 12/17/2022] Open
Abstract
Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon cause of gastrointestinal hemorrhage. Hemobilia has been documented since the 1600s, but due to its relative rarity, it has only been more critically examined in recent decades. Most cases of hemobilia are iatrogenic and caused by procedures involving the liver, pancreas, bile ducts, and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other major causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described, but this is present in only 25-30% of patients with hemobilia. Historically, the gold standard for diagnosis and treatment has been angiography and interventional radiologic intervention, respectively. However, the paradigm is shifting, at least in select cases, towards first-line reliance on noninvasive imaging (e.g., computed tomography) and therapeutic endoscopy, owing to advances in and the less invasive nature of both, while saving interventional radiological and/or surgical intervention for refractory or imminently life-threatening cases.
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Affiliation(s)
- Rani Berry
- Department of Internal Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - James Han
- Department of Internal Medicine, University of California, Irvine, CA, USA
| | - Mohit Girotra
- Division of Gastroenterology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
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13
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Cathcart S, Birk JW, Tadros M, Schuster M. Hemobilia: An Uncommon But Notable Cause of Upper Gastrointestinal Bleeding. J Clin Gastroenterol 2017. [PMID: 28644311 DOI: 10.1097/mcg.0000000000000876] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL AND BACKGROUND A literature review to improve practitioners' knowledge and performance concerning the epidemiology, diagnosis, and management of hemobilia. STUDY A search of Pubmed, Google Scholar, and Medline was conducted using the keyword hemobilia and relevant articles were reviewed and analyzed. The findings pertaining to hemobilia etiology, investigation, and management techniques were considered and organized by clinicians practiced in hemobilia. RESULTS The majority of current hemobilia cases have an iatrogenic cause from either bile duct or liver manipulation. Blunt trauma is also a significant cause of hemobilia. The classic triad presentation of right upper quadrant pain, jaundice, and upper gastrointestinal bleeding is rarely seen. Computed tomography and magnetic resonance imaging are the preferred diagnostic modalities, and the preferred therapeutic management includes interventional radiology and endoscopic retrograde cholangiopancreatography. Surgery is rarely a therapeutic option. CONCLUSIONS With advances in computed tomography and magnetic resonance imaging technology, diagnosis with these less invasive investigations are the favored option. However, traditional catheter angiography is still the gold standard. The management of significant hemobilia is still centered on arterial embolization, but arterial and biliary stents have become accepted alternative therapies.
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Affiliation(s)
- Scott Cathcart
- *Albany Medical Center, Albany Medical College Departments of §Radiology ‡Gastroenterology & Hepatology, Albany Medical Center, Albany, NY †Division of Gastroenterology & Hepatology, Gastroenterology & Hepatology Fellowship Program, UConn School of Medicine, Farmington, CT
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Lee HW, Shah NH, Lee SK. An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications. Clin Endosc 2017; 50:451-463. [PMID: 28415168 PMCID: PMC5642064 DOI: 10.5946/ce.2016.139] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/16/2017] [Accepted: 02/22/2017] [Indexed: 02/07/2023] Open
Abstract
Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%-45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques-such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy-combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.
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Affiliation(s)
- Hyun Woo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Najmul Hassan Shah
- Division of Gastroenterology and Hepatology, Liver Transplant Program, Shifa International Hospital Ltd., Shifa College of Medicine, Islamabad, Pakistan
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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