Air cholangiogram: a new technique for biliary imaging during ERCP

Endoscopic Ultrasound-Guided Hepaticogastrostomy for a Benign Biliary Stricture in a Patient Allergic to Both Iodinated and Gadolinium Contrast Media: A Case Report

Allergic reactions to iodinated and gadolinium contrast media, though rare, present significant challenges in managing biliary obstructions. This case report describes a novel approach to biliary drainage in a patient with such allergies using endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS). An 81-year-old woman with multiple allergies, including to both iodinated and gadolinium contrast media, developed a benign biliary stricture following repeated radiofrequency ablation for hepatocellular carcinoma. Standard endoscopic retrograde cholangiopancreatography was contraindicated due to these allergies. An EUS-HGS was successfully performed, achieving effective biliary drainage through ultrasound-guided puncture and stent placement without the use of contrast agents. The procedure was complication-free, and the patient's hepatobiliary enzyme levels improved significantly postoperatively. An EUS-HGS offers a safe and effective alternative for biliary drainage in patients with dual contrast agent allergies, especially when conventional methods are not viable. This case highlights the potential of EUS-HGS in addressing complex clinical challenges.

Using air cholangiography to reduce postendoscopic retrograde cholangiopancreatography cholangitis in patients with malignant hilar obstruction

BACKGROUND

Cholangitis after endoscopic retrograde cholangiopancreatography (ERCP) is a major problem for patients with hilar biliary obstruction. To date, it remains unclear whether air-contrast cholangiography (ACC) can reduce cholangitis in these patients. For this reason, our study assesses the efficacy of reducing cholangitis through ACC.

METHODS

This paper presents a retrospective study conducted at a tertiary university hospital. We enrolled patients who were diagnosed with hilar structures and underwent ERCP between January 2012 and December 2018. From 2015 onwards, ACC was performed following the successful selective cannulation into the dilated intrahepatic bile duct of these patients. The primary aim was to assess patients with cholangitis in both an ACC group and iodine contrast cholangiography (ICC) group.

RESULTS

This study included 80 patients, 35 of whom received ACC and 45 who received ICC. There were no differences between the 2 groups in terms of the number of patients who underwent endoscopic papillotomy, endoscopic nasobiliary drainage, endoscopic biliary stent placement, or other technical procedures or complications. A total of 19 patients (23.8%) presented with fever (cholangitis) after the ERCP procedure (4 ACC, 15 ICC; 11.4% vs. 33.3%, respectively; P=0.03). One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. Among the other 18 cholangitis patients, 8 (1 ACC, 7 ICC) were treated with additional ERCP or percutaneous transhepatic biliary drainage (PTBD), while the remaining 10 only received antibiotics. One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP.

CONCLUSIONS

We found that ACC significantly reduced the incidence of cholangitis in patients with hilar obstruction.

Plastic versus metal stents for inoperable gallbladder cancer with hilar biliary obstruction: the jury is still out

In unresectable malignant hilar obstruction, adequate biliary drainage can be achieved with endoscopic placement of plastic or metal stents. Stent patency and patient survival may differ, depending on the primary disease, disease progression and stent type. Metal and plastic stents were compared in patients with malignant hilar strictures in several studies, but these studies mainly included patients who had cholangiocarcinoma, without taking into consideration potential differences in the invasion properties of tumor cells, histological differentiation and the biological behavior of different tumors. Gallbladder cancer (GBC) is the most common malignancy of the biliary tract, especially in the Indian subcontinent and Latin America. About half the patients with GBC present with jaundice, which usually means the tumor is inoperable. Palliative endoscopic stenting remains the first-line treatment of unresectable GBC with biliary obstruction. Primary disease progression is faster in GBC compared to cholangiocarcinoma. There is a paucity of data on the selection of stents for inoperable GBC with hilar biliary obstruction. This review focuses on the published literature related to the selection of stents for unresectable GBC with hilar obstruction.

CO2 or air cholangiography reduces the risk of post-ERCP cholangitis in patients with Bismuth type IV hilar biliary obstruction

Background

Endoscopic biliary stenting by endoscopic retrograde cholangiopancreatography (ERCP) is the most common form of palliation for malignant hilar obstruction. However, ERCP in such cases is associated with a risk of cholangitis. The incidence of post-ERCP cholangitis is particularly high in Bismuth type IV hilar obstruction, and this risk is further increased when the contrast injected for cholangiography is not drained. The present study aims to compare the incidence of cholangitis associated with the use of a contrast agent, air and CO₂ for cholangiography in type IV hilar biliary lesions.

Methods

The clinical data of consecutive 70 patients with type IV hilar obstruction, who underwent ERCP from October 2013 to November 2017, were retrospectively analyzed. These patients were divided into three groups based on the agent used for cholangiography: group A, contrast (n = 22); group B, air (n = 18); group C, CO₂ (n = 30). These three methods of cholangiography were chronologically separated. Prior to the ERCP, MRCP was obtained from all patients to guide the endoscopic intervention.

Results

At baseline, there was no significant difference in terms of the patient’s age, gender, symptoms and liver function tests among the three groups (P > 0.05). The complication rates were significantly higher in group A than in groups B and C (63.6% vs. 26.7 and 27.8%, P < 0.05). The incidence of post-ERCP cholangitis was significantly higher in group A (P < 0.05), while the incidence of post-ERCP pancreatitis and bleeding were similar in the three groups. After the ERCP, the mean hospital stay was shorter in groups B and C, when compared to group A (P < 0.05). However, there was no significant difference in the 30-day mortality rate among the three groups (P > 0.05). Furthermore, there was no significant difference between groups B and C in terms of primary end points.

Conclusion

CO₂ or air cholangiography during ERCP for type IV hilar obstruction is associated with reduced risk of post-ERCP cholangitis, when compared to conventional contrast agents.

An unexpected case of iatrogenic Escherichia coli endogenous pan-endopthalmitis after ERCP-associated biliary sepsis: A case report

INTRODUCTION

Endogenous endopthalmitis is a diagnostically challenging ophthalmic and medical emergency. It has the ability to manifest at any age and is associated with a number of predisposing factors. The rapid progression of disease poses catastrophic risk for adverse outcomes both localised and systemic. To our knowledge, we describe the first reported iatrogenic case of endogenous Escherichia coli-induced endopthalmitis progressing to pan-endopthalmitis as a consequence of endoscopic retrograde cholangiopancreatography.

DIAGNOSIS, INTERVENTIONS AND OUTCOMES

The patient presented with reduced visual acuity and painless red eye; however, apart from biochemistry results suggesting biliary sepsis, no other clinical features of acute disease were noted. Despite rigorous systemic and intravitreal treatment, the rapid progression of disease led to irreversible damage to the eye.

CONCLUSION

Clinicians must maintain a very high index of suspicion when encountering patients after interventional procedures, as misdiagnosis by trained ophthalmologists for endogenous endopthalmitis remains a common occurrence. Prompt identification and diagnosis ensured our patient avoided evisceration and early ophthalmic biopsies guaranteed the correct systemic intervention was started to address the severe subsequent septicaemia.

Air cholangiography in endoscopic bilateral stent-in-stent placement of metallic stents for malignant hilar biliary obstruction

BACKGROUND

Although endoscopic bilateral stent-in-stent (SIS) placement of self-expandable metallic stents (SEMS) is one of the major palliative treatments for unresectable malignant hilar biliary obstruction, post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis can occur frequently due to inadequate drainage, especially after contrast injection into the biliary tree. The aim of this study is to evaluate the efficacy and safety of air cholangiography-assisted stenting.

METHODS

This study included 47 patients with malignant hilar biliary obstruction who underwent endoscopic bilateral SEMS placement using the SIS technique. They were divided into two groups, air (n = 23) or iodine contrast (n = 24) cholangiography. We retrospectively compared comprehensive clinical and laboratory data of both groups.

RESULTS

There were no significant differences found between the two groups with respect to technical success (87% versus 87.5%, air versus contrast group, respectively), functional success (95% versus 95.2%), 30-day mortality (8.3% versus 8.7%) and stent patency. Post-ERCP adverse events occurred in 5 (21.7%) of the patients in the air group and 8 (33.3%) of the patients in the contrast group. Among these, the rate of cholangitis was significantly lower in the air group (4.8% versus 29.2%, p = 0.048). In multivariate analysis, air cholangiography, technical success and a shorter procedure time were significantly associated with a lower incidence of post-ERCP cholangitis.

CONCLUSIONS

Air cholangiography-assisted stenting can be a safe and effective method for endoscopic bilateral SIS placement of SEMS in patients with malignant hilar biliary obstruction.

Endoscopic management of hilar biliary strictures

Hilar biliary strictures are caused by various benign and malignant conditions. It is difficult to differentiate benign and malignant strictures. Postcholecystectomy benign biliary strictures are frequently encountered. Endoscopic management of these strictures is challenging. An endoscopic method has been advocated that involves placement of increasing number of stents at regular intervals to resolve the stricture. Malignant hilar strictures are mostly unresectable at the time of diagnosis and only palliation is possible.Endoscopic palliation is preferred over surgery or radiological intervention. Magnetic resonance cholangiopancreaticography is quite important in the management of these strictures. Metal stents are superior to plastic stents. The opinion is divided over the issue of unilateral or bilateral stenting.Minimal contrast or no contrast technique has been advocated during endoscopic retrograde cholangiopancreatography of these patients. The role of intraluminal brachytherapy, intraductal ablation devices, photodynamic therapy, and endoscopic ultrasound still remains to be defined.

Air cholangiogram is not inferior to dye cholangiogram for malignant hilar biliary obstruction: a randomized study of efficacy and safety

BACKGROUND

Endoscopic biliary drainage is the palliative treatment of choice in patients with malignant hilar biliary obstruction. Contrast injection can lead to cholangitis, whereas air cholangiography may have a lesser incidence of cholangitis.

OBJECTIVE

The objective of the present study is to prospectively compare the efficacy and safety of air vs. dye cholangiogram in malignant hilar biliary obstruction.

METHODS

Patients with type II and III malignant hilar biliary stricture were included in a prospectively randomized manner at a tertiary care center. Unilateral self-expanding metal stent was placed in patients with a malignant hilar block using either air or dye as a contrast medium. Outcome measures were successful deployment, successful drainage, early complications, and procedure-related and 30-day mortality.

RESULTS

Forty-nine patients were randomized to air cholangiogram (25 patients, group A) or dye cholangiogram (24 patients, group B). Most of the patients had type II stricture (19 in group A and 20 in group B). Successful stenting and drainage were achieved in 25 (100 %) and 24 (96 %) in group A and 23 (95.8 %) and 22 (91.6 %) (p = ns), respectively. Cholangitis developed in 1 (4 %) and 4 (16.6 %) in group A and B, respectively (p < 0.05). There was no procedure-related or 30-day mortality.

CONCLUSION

Use of air cholangiography was as safe and as effective as dye cholangiography in patients with malignant hilar biliary obstruction, and it decreased the risk of post-ERCP cholangitis.

Effect of CO2 cholangiography on post-ERCP cholangitis in patients with unresectable malignant hilar obstruction - a prospective, randomized controlled study

BACKGROUND

Air cholangiogram has been used in patients with malignant hilar obstruction to reduce cholangitis after endoscopic retrograde cholangiopancreatography (ERCP). However, it still remains unclear whether CO2 could be used as an alternative for air cholangiography in such patients.

OBJECTIVE

To investigate the effect of CO2 cholangiogram on post-ERCP complications.

DESIGN

Prospective, randomized controlled study.

SETTING

Tertiary care referral center.

PATIENTS

36 patients with Bismuth type II, III or IV were randomized into CO2 group or iodine contrast group (control group).

INTERVENTION

Cholangiography was performed by injection of either CO2 or iodine contrast through a sphincterotome. One or two metal stents were placed.

MAIN OUTCOME MEASURES

Post-ERCP complications, length of hospital stay after ERCP, 1-month and 1-year mortality.

RESULT

There was no significant difference in age, gender, symptoms, liver function tests, type of tumor origin and Bismuth type between patients in CO2 and contrast groups (p > 0.05). Compared with one-stent placement, more volume of CO2 and longer operation time were observed when performing two-stent placement (both p < 0.05). The rate of cholangitis in CO2 group was significantly lower than that in control group (5.6% vs. 33.3%, p = 0.04). After ERCP, mean hospital stay time was shorter in CO2 group compared with control (p < 0.05). The difference of 1-month and 1-year mortality between two groups was not significant (both p > 0.05).

CONCLUSION

CO2 cholangiogram could be a safe method to visualize intrahepatic bile duct with low incidence of post-ERCP cholangitis, which could be considered for the patients with malignant hilar obstruction.