Choledochal varices bleeding: A case report

Successful Hemostasis Using Fully Covered Self-Expanding Metallic Stent for Spontaneous Hemobilia in a Child With Portal Cavernoma Cholangiopathy

Portal cavernoma cholangiopathy refers to changes in the intrahepatic and extrahepatic biliary ducts in patients with extrahepatic portal venous obstruction. Spontaneous hemobilia in the setting of portal cavernoma cholangiopathy is extremely rare, and it poses diagnostic as well as therapeutic challenge. Here, we report the case of a 10-year-old girl with extrahepatic portal venous obstruction, who presented with hemobilia. Computed tomography angiography of abdomen and endoscopic ultrasound confirmed the presence of pericholedochal, paracholedochal, and intracholedochal varices. Hemostasis was achieved with the placement of a fully covered self-expanding metallic stent into the common bile duct. Fully covered self-expanding metallic stent is safe and effective for control of bleeding in children presenting with hemobilia.

[Ectopic biliary varices as a cause of portal biliopathy and mechanical jaundice syndrome]

The authors consider ectopic biliary varices as a possible cause of portal biliopathy in extrahepatic portal hypertension. The main diagnostic methods including ultrasound CT, MRI, endoscopic ultrasonography, cholangioscopy, difficulties of differential diagnosis and clinical manifestations of portal biliopathy are presented. Various treatment options including portosystemic shunting and endoscopic biliary decompression are discussed. The authors emphasize the role of differentiated treatment depending on bile duct lesions. The study not only reviews this problem, but also highlights the issues requiring further analysis for selection of optimal diagnostic and treatment methods.

Comparative evaluation of magnetic resonance cholangiopancreatography/magnetic resonance splenoportovenography and endoscopic ultrasound in the diagnosis of portal cavernoma cholangiopathy

BACKGROUND

Magnetic resonance cholangiopancreatography/magnetic resonance splenoportovenography (MRCP/MRSPV) is now the investigation of choice for the diagnosis of portal cavernoma cholangiopathy (PCC). Endoscopic ultrasound (EUS) is an emerging diagnostic modality for the diagnosis of PCC and may be better than MRCP/MRSPV to see the layer-wise localization of varices and to differentiate between varices, stone, and malignancy.

METHODS

Retrospective data of 50 patients of extrahepatic portal vein obstruction (EHPVO) were collected, and comparison between MRCP/MRSPV and EUS was done for the diagnosis of PCC.

RESULTS

Out of 50 patients, 56 % (28) were males, 44 % (22) females, and 24 % (12) symptomatic. Biliary changes were seen in 40 patients (80 %). Epicholedochal collateral (EPEC) was detected in 48 % and 20 % in MRCP/MRSPV and EUS, respectively. Perforators (PER) and intracholedochal collateral (ICC) were better seen with EUS (72 % and 48 %) as compared to MRCP/MRSPV (0 % and 8 %), and p-values were significant (<0.05). EUS has a sensitivity of 33.33 % and a specificity of 92.31 % for EPEC. Portal cavernoma (PC) and collateral at porta (CP), paracholedochal collateral (PAC), perisplenic (PS) and peripancreatic collateral (PPC), pericholedochal collateral (PEC), intrahepatic biliary radical dilatation (IHBRD), perigallbladder collateral (PG), common bile duct dilatation (CBDD) and common hepatic duct dilatation (CHDD), common bile duct stricture (CBDS), and retropancreatic collateral (RPC) were comparable between the two modalities.

CONCLUSIONS

EUS detected PER and ICC better than MRCP/MRSPV, while MRCP/MRSPV was more sensitive for detecting EPEC.