Traumatic neuroma of the bile ducts with intrahepatic extension causing obstructive jaundice

Epidemiology, risk factors, diagnosis, and treatment of intra-abdominal traumatic neuromas - a narrative review

Traumatic neuroma (TN) is a disorganized proliferation of injured nerves arising from the axons and Schwann cells. Although TN rarely occurs in the abdominal cavity, the incidence of TN may be underestimated because of the large number of asymptomatic patients. TN can cause persistent pain, which seriously affects quality of life. TN of the biliary system can cause bile duct obstruction, leading to acute cholangitis. It is difficult to differentiate TN from malignancies or recurrence of malignancy, which results in a number of patients receiving aggressive treatment. We collected cases reports of intra-abdominal TN over the past 30 years form PubMed and cases diagnosed in our medical center over the past 20 years, which is the largest case series of intra-abdominal TN to the best of our knowledge. In this review, we discuss the epidemiology, pathophysiology, risk factors, classification, diagnosis, and management of intra-abdominal TN.

Contrast-enhanced ultrasound of a traumatic neuroma of the extrahepatic bile duct: A case report and review of literature

BACKGROUND

Traumatic neuromas result from nerve injury after trauma or surgery but rarely occur in the bile duct. However, it is challenging to diagnose traumatic neuromas correctly preoperatively. Although some previous reports have described the imaging features of traumatic neuroma in the bile duct, no features of traumatic neuromas in the bile duct have been identified by using contrast-enhanced ultrasound (CEUS) imaging before.

CASE SUMMARY

A 55-year-old male patient presented to our hospital with a 3-mo history of abdominal distension and anorexia and history of cholecystectomy 4 years ago. Grayscale ultrasound demonstrated mild to moderate intrahepatic bile duct dilatation. Meanwhile, a hyperechoic nodule was found in the upper extrahepatic bile duct. The lesion approximately 0.8 cm × 0.6 cm with a regular shape and clear margins. The nodule of the bile duct showed slight hyperenhancement in the arterial phase and isoenhancement in the venous phase on CEUS. Laboratory tests showed that alanine aminotransferase and aspartate aminotransferase were increased significantly, while the tumor marker carbohydrate antigen 19-9 was increased slightly. Then, hilar bile duct resection and end-to-end bile ductal anastomosis were performed. The histological examination revealed traumatic neuroma of the extrahepatic bile duct. The patient had an uneventful recovery after surgery.

CONCLUSION

The current report will help enhance the current knowledge regarding identifying traumatic neuromas by CEUS imaging and review the related literature.

Diffuse Neuromatosis of Intrahepatic and Extrahepatic Bile Ducts as a Rare Cause of Jaundice

Background

Neuroma of the biliary tree is extremely rare with no more than 100 cases reported so far. They mostly present with obstructive jaundice and have been commonly described after surgery or abdominal trauma. Although involvement of the extrahepatic bile duct is far more common, occurrence in the intrahepatic ducts has not so far been reported.

Case Report

We describe 3 cases of diffuse biliary tree neuroma affecting 3 females aged 53-68 years. None had a history of neurofibromatosis type1. All presented with progressive obstructive jaundice with no evidence of gallstones. A history of previous surgery was noted in 2 patients. Initial impression on clinical and imaging examination was highly suspicious for bile duct carcinoma in 2 patients. Histology showed diffuse neuromatous proliferation replacing and thickening the bile duct walls. The third patient had concurrent neuroma and recurrent cholangiocarcinoma causing great clinical confusion as initial biopsy showed only benign neuroma, but CA 19-9 was steadily increasing, necessitating a second biopsy which then confirmed recurrent carcinoma.

Conclusion

This uncommon cause of long-distance bile duct stenosis and progressive jaundice should be included in the differential diagnosis of bile duct neoplasms, in particular when there is a previous surgical history in this abdominal region.

A late unusual complication after an open cholecystectomy: Amputation neuroma of the CBD causing obstructive jaundice

INTRODUCTION

Cholecystectomy is one of the most frequently done procedures in general surgery. There are few reports of amputation neuromas following this procedure. This presentation describes a case of obstructive jaundice due to amputation neuroma in a patient with a history of cholecystectomy.

CASE PRESENTATION

We report about a 53 y o lady who presented with obstructive jaundice, 8 years following open cholecystectomy. Paraclinical investigations were in favor of cholangicarcinoma, however the final pathology revealed an amputation neuroma of the CBD.

DISCUSSION

Amputation neuromas are rarely seen in the era of laparoscopic cholecystectomy. They are benign reparative lesions of the CBD following surgery or manipulation of the extra hepatic biliary tree. It is very difficult to diagnose them pre-operatively. Surgical resection is the first choice of treatment.

CONCLUSION

Traumatic neuromas should always be among the differential diagnosis, when assessing a CBD mass in patients with a previous history of open cholecystectomy or surgery to the gastrointestinal tract.

Well-differentiated neuroendocrine (carcinoid) tumors of the extrahepatic biliary ducts

Primary, well-differentiated neuroendocrine (carcinoid) tumors of the extrahepatic biliary ducts are an uncommon cause of biliary obstruction. As compared to cholangiocarcinomas, which are more commonly seen at this location, these tumors tend to behave less aggressively, and only one-third metastasize. Tumor size (>2 cm) appears to be the best predictor of aggressive behavior. Surgery is the mainstay of treatment and complete resection offers prolonged disease-free survival. Accurate preoperative diagnosis is therefore important and can be made by examining brush cytology specimens obtained during endoscopic retrograde cholangiopancreatography and/or endoscopic ultrasound-guided fine-needle aspiration. It is important to keep this entity in mind, especially when examining cytologic or small biopsy specimens, so that appropriate immunohistochemical stains can be used to arrive at the correct diagnosis.

Extrahepatic bile duct stricture and elevated CA 19-9: malignant or benign?

Biliary obstruction due to a proximal bile duct stricture is commonly a result of cholangiocarcinoma. We describe a patient who began having intermittent episodes of jaundice 3 years after cholecystectomy. Despite endoscopic placement of a biliary stent and adequate biliary decompression, the serum CA 19-9 level remained elevated at 58 U/ml (normal <37 U/ml). Segmental bile duct resection and Roux-en-Y hepaticojejunostomy were done. The stricture was caused by a traumatic bile duct neuroma. Diagnostic and therapeutic considerations of this entity are discussed, with special emphasis on the value of noninvasive biliary imaging by magnetic resonance imaging (MRI), the utility and interpretation of the CA 19-9 level, and the role for resection or surgical biliary decompression.

Neuromas of the extrahepatic bile ducts as a cause of obstructive jaundice

We present four cases of extrahepatic bile duct neuromas causing obstructive jaundice. Two patients with neuromas localized in the hepatic duct had no evidence of gallstones or history of previous surgery. In these subjects, partial resection of the common bile duct and cholecystectomy was followed by hepatico-jejunostomy with Roux-en-Y reconstruction. In another patient, 7 years after cholecystectomy, a neuroma localized in the hepatic duct was treated by insertion of a T-tube. In the fourth patient, 9 years after laparoscopic cholecystectomy, partial common bile duct resection and Roux-en-Y hepatico-jejunostomy was performed. In all cases, the correct diagnosis of this very rare cause of extrahepatic bile duct obstruction was established postoperatively.

An Unusual Etiology of Biliary Hilar Obstruction and the Potential Role of Acidic Fibroblast Growth Factor in the Development of a Biliary Neuroma

Neuroma of the biliary tract is a rare condition thought to be caused by trauma secondary to cholecystectomy. More rare is the occurrence that causes symptomatic biliary obstruction. A 65-year-old woman was hospitalized because of abdominal pain, nausea, vomiting, and general malaise of 1 to 2 months duration. Cholecystectomy had been performed 40 years before. Ultrasound revealed hepatomegaly and dilated intrahepatic ducts. CT showed intra- and extrahepatic ductal dilatation with questionable intraductal mass. Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography demonstrated stricture of the hepatic duct bifurcation. The biliary bifurcation was resected, and hepaticojejunostomy was performed. The patient's postoperative course was unremarkable. Histological examination of the surgical specimen revealed positive staining for the S-100 antigen of the obstructing luminal stricture (without evidence of cholangiocarcinoma), which was consistent with a biliary neuroma. Positive staining was also found for acidic (and not basic) fibroblast growth factor (FGF) and two of its high affinity receptors (FGFR-1 and FGFR-4). This study supports the apparent association between biliary neuromas and cholecystectomy as well as the potential role of an established angiogenic and neurogenic growth factor in the formation of this tumor. Finally, this case is also unique in that it represents the longest interval between cholecystectomy and presentation of a biliary neuroma, 40 years after surgery.

Non Traumatic Neuroma of the Bile Duct: Report of a Case

We report a case of a 46-year-old man with a stricture of the bile duct which was caused by neuroma. The patient had a history of six months jaundice without a previous history of abdominal surgical operation. MR imaging and MRCP clearly picked up the dilatation of intrahepatic biliary ducts and the level of stenosis, but it was very difficult to differentiate benign neuroma from malignant stenosis of the common bile duct. Results of preoperative CT, MRI and ERCP evaluation and postoperative histological examination were presented.

Amputation neuroma of the hepatic hilum after orthotopic liver transplantation

Amputation neuromas following biliary surgery have been previously reported. There are no descriptions, however, of amputation neuroma following liver transplantation. Serial hilum sections taken from 93 hepatectomy specimens obtained during the clinical course of 262 consecutive orthotopic liver transplantations revealed 26 amputation neuromas (27.9% of the specimens examined). The finding was confirmed by immunohistochemistry with numerous S-100 protein positive cells intermingled with neurofilaments interrupting the perineurial layer of cells testing positive for epithelial membrane antigen. Neuromas were found in liver specimens obtained between 89 and 775 days post-transplant (mean time, 211 days). The incidence of neuroma was higher in specimens resected more than 3 months post-transplant. There was only one symptomatic patient, who died from extrahepatic cholestasis demonstrated at autopsy to be caused by a hilar neuroma obstructing the main bile duct.

Benign schwannoma in the hepatoduodenal ligament: report of a case

A 62-year-old woman with a large mass in the hepatic hilus underwent surgery. Histologically the tumor was predominantly composed of spindle-shaped cells with nuclear palisading and cells that stained positively for S-100 protein. The diagnosis was benign schwannoma (neurilemoma). The presence of lymphoid cuffing with lymphoid follicles in the capsule and xanthomatous change differed from conventional soft parts schwannoma and closely resembled benign schwannoma in the gastrointestinal tract.

Traumatic neuroma at the tail of the pancreas following splenectomy

A 50 year old man presented with abdominal pain and weight loss after a splenectomy performed 26 years ago for abdominal trauma. At laparotomy, a mass was found at the tail of the pancreas. Pathological examination showed this was a traumatic neuroma and revealed evidence of chronic pancreatitis. Traumatic neuroma may be a rare cause of a pancreatic mass, especially after previous surgery or trauma.

Neuroma of the common bile duct

Two cases of neuroma of the common bile duct (CBD) associated with jaundice and cholangitis both 15 years after cholecystectomy are presented. The surgical treatment, excision of the diseased CBD, followed by Roux-en-Y biliary drainage in one case and excision of the tumor with T-tube drainage in the other, was curative. A review of the world literature revealed 20 prior cases of CBD neuromas, 19 associated with jaundice. None was diagnosed prior to operation or autopsy. Mortality of treatment was 15% and all deaths were associated with a failure to excise the neuroma.