Bile duct varices

An Uncommon Cause of Biliary Obstruction in a Patient With Budd-Chiari Syndrome

Biliary varices (BVs) are an infrequent complication of chronic portal hypertension. Most cases of BVs are asymptomatic and are likely underdiagnosed. We present a case of a 34-year-old woman with Budd-Chiari syndrome who was found to have BVs caused by a significant inferior vena cava (IVC) stenosis. This case demonstrates that preprocedure imaging for variceal screening should be considered before biliary tract procedures to prevent complications.

Portal Cholangiopathy: An Uncommon Cause of Right Upper Quadrant Pain

Portal cholangiopathy is one of the complications of the chronic portal vein thrombosis (PVT). Chronic PVT can occur in a patient with acute PVT that usually does not resolve regardless of the treatment. There is a development of collateral blood vessels that bring blood from the portal system towards the liver around the obstruction area, known as the cavernous transformation of the portal vein or portal cavernoma, in a patient with chronic PVT. The appearance and location of collateral channels depends on the extent and location of thrombus in the portomesenteric venous system. If the portomesenteric venous system is occluded near the formation of the portal vein, blood tends to flow through collateral channels that form varices in and around the common bile duct. Portal cholangiopathy (also referred to as portal biliopathy) is common in patients with long-standing chronic PVT. It is due to compression of the large bile ducts by the venous collaterals that form in patients with chronic PVT. Most of the patients with long-standing PVT have portal cholangiopathy. Typically, symptoms of portal cholangiopathy include jaundice, biliary colic, and pruritus. Portal cholangiopathy is a rare complication of chronic portal hypertension, and it is an important differential diagnosis of biliary colic secondary to cholelithiasis. The patient can also present with the sharp right upper quadrant pain, which is atypical by nature for biliary colic.

Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation

Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.

Intraductal ultrasonographic anatomy of biliary varices in patients with portal hypertension

BACKGROUND AND OBJECTIVES

The term, portal biliopathy, denotes various biliary abnormalities, such as stenosis and/or dilatation of the bile duct, in patients with portal hypertension. These vascular abnormalities sometimes bring on an obstructive jaundice, but they are not clear which vessels participated in obstructive jaundice. The aim of present study was clear the bile ductal changes in patients with portal hypertension in hopes of establishing a therapeutic strategy for obstructive jaundice caused by biliary varices.

MATERIALS AND METHODS

Three hundred and thirty-seven patients who underwent intraductal ultrasound (IDUS) during endoscopic retrograde cholangiography for biliary abnormalities were enrolled. Portal biliopathy was analyzed using IDUS.

RESULTS

Biliary varices were identified in 11 (2.7%) patients. IDUS revealed biliary varices as multiple, hypoechoic features surrounding the bile duct wall. These varices could be categorized into one of two groups according to their location in the sectional image of bile duct: epicholedochal and paracholedochal. Epicholedochal varices were identified in all patients, but paracholedochal varices were observed only in patients with extrahepatic portal obstruction.

CONCLUSION

IDUS was useful to characterize the anatomy of portal biliopathy in detail.

Portal cavernoma cholangiopathy - history, definition and nomenclature

Biliary changes secondary to portal hypertension, especially in portal cavernoma secondary to extrahepatic portal vein obstruction have long been described in literature under different names by various authors. Most of the times these changes are asymptomatic and discovered on imaging, but can occasionally cause obstructive jaundice. There is no consensus on the appropriate nomenclature and definition of this entity. This article reviews the history of portal hypertensive biliopathy and the Indian Association for the Study of Liver Working Party consensus definition and nomenclature for it.

Portal cavernoma cholangiopathy: consensus statement of a working party of the Indian national association for study of the liver

Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.

Vascular biliopathy as a cause of common bile duct obstruction successfully treated by mesocaval shunt and endoscopic retrograde cholangiopancreatography biliary stent placement

Common bile duct stenosis owing to extrahepatic portal varices is termed "portal hypertensive biliopathy" (PHB) and is a rare occurrence. We report a case of PHB owing to portal vein thrombosis with cavernous transformation successfully managed by mesocaval shunt and endoscopic retrograde cholangiopancreatography (ERCP) biliary stent placement. A 44-year-old male, who presented with hematemesis, melena, jaundice, and abdominal pain, underwent gastroscopy, which revealed bleeding gastric varices. Computed tomography with arterial and venous imaging demonstrated portal vein thrombosis with cavernous transformation and extensive extrahepatic varices within the porta hepatis causing common bile duct obstruction from extrinsic compression. Biliary decompression was achieved with ERCP, and a small common bile duct stone was retrieved. A mesocaval shunt with a 16 mm Dacron graft successfully treated the portal hypertension. PHB is rare. We report a case successfully treated by mesocaval shunt and ERCP.

Sclerosing cholangitis: a focus on secondary causes

Secondary sclerosing cholangitis (SSC) is a disease that is morphologically similar to primary sclerosing cholangitis (PSC) but that originates from a known pathological process. Its clinical and cholangiographic features may mimic PSC, yet its natural history may be more favorable if recognition is prompt and appropriate therapy is introduced. Thus, the diagnosis of PSC requires the exclusion of secondary causes of sclerosing cholangitis and recognition of associated conditions that may potentially imitate its classic cholangiographic features. Well-described causes of SSC include intraductal stone disease, surgical or blunt abdominal trauma, intra-arterial chemotherapy, and recurrent pancreatitis. However, a wide variety of other associations have been reported recently, including autoimmune pancreatitis, portal biliopathy, eosinophillic and/or mast cell cholangitis, hepatic inflammatory pseudotumor, recurrent pyogenic cholangitis, primary immune deficiency, and AIDS-related cholangiopathy. This article offers a comprehensive review of SSC.

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Endoscopic management of biliary obstruction caused by cavernous transformation of the portal vein

BACKGROUND

Symptomatic biliary obstruction caused by cavernous transformation of the portal vein is an extremely rare disorder for which there is no consensus as to optimal treatment. The results of endoscopic treatments in a small group of patients is reviewed.

METHODS

A total of 10 patients (5 men, 5 women; mean age 36.1 years, range 17-48 years) with severe biliary strictures were treated between 1995 and 2001. Biliary sphincterotomy was performed in all patients. Four patients also underwent balloon dilation, nasobiliary drainage, and stone or sludge extraction by using a balloon. All patients had stent insertion.

OBSERVATIONS

The mean duration of therapy was 3.3 years (range 1-7 years). There was no complication directly related to the endoscopic procedures except for hemobilia that occurred in one patient during stent removal. Cholangitis developed in 5 patients during the therapy period and was treated endoscopically. In 4 patients, significant improvement in the biliary stricture was observed and stents were removed in 3. These patients were followed without stent insertion for one year.

CONCLUSIONS

Endoscopic management of biliary stricture caused by cavernous transformation of the portal vein appears to be effective and safe.

[Portal cavenorma: diagnosis, aetiologies and consequences]

Portal cavernoma is a network of veins whose caliber, initially millimetric or microscopic, is increased and which contain hepatopedal portal blood. It results from occlusion, thrombotic and always chronic, of the extra-hepatic portal system. Diagnosis is mainly done by imaging. Clinical signs of portal cavernoma are usually related to extra-hepatic portal hypertension (hematemesis due to rupture of oeso-gastric varices, splenomegaly, rectal bleeding from ano-rectal varices, growth retardation in children) and sometimes to the cause of portal hypertension (abdominal pain, venous bowel infarction). Occurrence of portal thrombosis is often the conjunction of a local cause and a prothrombotic disorder which must be systematically detected. Biliary consequences of cavernoma are related to compression of common bile duct and are usually asymptomatic. In case of jaundice or cholangitis, portal decompression by portosystemic shunt can be performed to treat both biliary symptoms and portal hypertension.

Portal biliopathy

In patients with portal hypertension, particularly with extrahepatic portal vein obstruction, portal biliopathy producing biliary ductal and gallbladder wall abnormalities are common. Portal cavernoma formation, choledochal varices and ischemic injury of the bile duct have been implicated as causes of these morphological alterations. While a majority of the patients are asymptomatic, some present with a raised alkaline phosphatase level, abdominal pain, fever and cholangitis. Choledocholithiasis may develop as a complication and manifest as obstructive jaundice with or without cholangitis. Endoscopic sphincterotomy and stone extraction can effectively treat cholangitis when jaundice is associated with common bile duct stone(s). Definitive decompressive shunt surgery is sometimes required when biliary obstruction is recurrent and progressive.

Liver transplantation in patients with portal vein thrombosis

The aim of this study is to analyze the incidence, risk factors, management, and follow-up of patients with portal vein thrombosis (PVT) undergoing primary orthotopic liver transplantation (OLT). Four hundred fifteen OLTs were performed in 391 patients. In 62 patients, partial (group 1; n = 48) or complete (group 2; n = 14) PVT was found at the time of surgery. Portal flow was reestablished by venous thrombectomy. In this study, we compare 62 primary OLTs performed in patients with PVT at the time of OLT with a group of 329 primary OLTs performed in patients without PVT (group 3) and analyze the incidence of PVT, use of diagnostic methods, surgical management, and outcome. We found no significant differences among the 3 groups for length of surgery, cold and warm ischemic times, and postoperative stay in the intensive care unit. With the piggyback technique, groups 1 and 2 had greater blood losses and required more blood transfusions than group 3. The early reoperation rate was greater in group 2. The incidence of rethrombosis was 4.8% (group 1, 2%; group 2, 14.3%). Reexploration and thrombectomy (2 patients) and retransplantation (1 patient) had a 100% mortality rate. In particular, the mortality rate of patients with complete PVT with extension into the splanchnic veins is high (33%). Three-month and 4-year patient survival rates were statistically similar in the 3 groups. The presence of PVT at the time of OLT is not a contraindication for OLT. However, if PVT extends into the splanchnic veins, the outcome is guarded.

Cholangiopathy associated with portal hypertension: diagnostic evaluation and clinical implications

BACKGROUND

There are few studies of biliary changes due to portal hypertension. We ascertained the incidence of such changes on endoscopic retrograde cholangiography and determined the reliability of biochemistry, ultrasonography (US) and hepatobiliary radionuclide scan in detecting this type of cholangiopathy.

METHODS

Forty-two patients with portal hypertension were studied.

RESULTS

Cholangiopathy was detected by cholangiography in 17 of 20 patients with extrahepatic portal venous obstruction. Abnormalities (mainly strictures and caliber irregularity) were seen in the common bile duct (5) and common hepatic duct (7) and in the right (8) and left (11) hepatic ducts (mainly dilatation). One of 11 patients with noncirrhotic portal fibrosis had a dilated right hepatic duct. Three of 11 patients with cirrhosis had pruned intrahepatic ducts. Eight patients with portal venous obstruction had elevated alkaline phosphatase levels; two had elevated bilirubin levels. US detected gallbladder varices (11) and choledochal varices (9) in patients with extrahepatic portal venous obstruction. Biliary abnormalities were detected on hepatobiliary scintigraphy in 16 of 17 patients.

CONCLUSIONS

Cholangiopathy associated with portal hypertension occurs exclusively in patients with extrahepatic portal venous obstruction. It rarely leads to functional obstruction; jaundice does not occur in the absence of functional blockage. Elevated alkaline phosphatase level (after excluding bile duct calculi), presence of gallbladder varices on US, and abnormal radionuclide scans are reliable in detecting these lesions.

Bile duct obstruction due to portal biliopathy in extrahepatic portal hypertension: surgical management

BACKGROUND

Varices can develop in and around the bile duct in the presence of portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis. The term 'portal biliopathy' is used to describe changes in the bile duct due to these varices, which may cause bile duct obstruction. This paper reviews experience of the surgical management of patients with symptomatic portal biliopathy.

METHODS

Nine patients with extrahepatic portal vein obstruction with symptomatic portal biliopathy. were reviewed retrospectively.

RESULTS

Eight patients presented with jaundice, two had abdominal pain and one had recurrent cholangitis. Endoscopic retrograde cholangiography revealed abnormality of the bile duct wall, with stricture in eight patients and bile duct calculi in two. Portasystemic shunting relieved jaundice in five of seven patients, and in two a second-stage hepaticojejunostomy was required.

CONCLUSION

Symptomatic biliary obstruction in patients with extrahepatic portal hypertension may be relieved by a portasystemic shunt. Rarely biliary bypass may be required and is rendered safer by previous portasystemic shunting to decompress the pericholedochal varices. A direct approach to the biliary tract without a preliminary shunt may be hazardous and is frequently unnecessary.

Successful endoscopic injection sclerotherapy for bleeding from bile duct varices

A 66-year-old man who had undergone hepatic resection and choledochojejunostomy for intrahepatic stones was admitted with dark bloody stools. An endoscopic examination failed to detect the origin of bleeding in the esophagus, stomach, duodenum, or colon. Angiography showed an obstruction of the main trunk of the portal vein and marked cavernous formation of the collateral veins in the hepatoduodenal ligament. The patient was finally found to have variceal bleeding arising from the common bile duct; this was revealed by an endoscopic examination done through a jejunocutaneous fistula created later on. Thereafter, endoscopic injection sclerotherapy was successfully used to treat the hemobilia.

Compression of the common bile duct due to portal-vein thrombosis in polycythemia vera

The case of a 56-yr-old patient with polycythemia vera who was initially seen with jaundice is reported. Compression of the common bile duct by choledochal varices was found to be the cause of the obstructive jaundice. This compression was successfully treated with placement of a plastic endoprosthesis across the stenosis during endoscopic retrograde cholangiopancreatography. The significance of choledochal varices in the evaluation of obstructive jaundice is emphasized.

Pseudosclerosing cholangitis in extrahepatic portal venous obstruction

Biliary changes secondary to portal hypertension have rarely been described in published reports. Twenty consecutive patients with extrahepatic portal venous obstruction, all of whom showed a variable degree of abnormalities in the biliary tract suggestive of sclerosing cholangitis, are described. These biliary abnormalities were: focal narrowing, dilatations, and cholangitic changes affecting the main bile ducts and hepatic ducts. The left hepatic duct and its branches were affected in all patients. Only one patient had clinical or biochemical evidence of cholestasis. The mechanism of these abnormalities in the biliary tract of these patients is perhaps the development of portal collaterals.

Haemorrhage from an adhesion-related mesenteric varix in a patient with portal hypertension

We report a case of profuse gastrointestinal haemorrhage from an ileal varix, in a segment of bowel adherent to the site of a previous incisional hernia repair, in a patient with portal hypertension. This is a rare but recognised complication of portal hypertension. Localisation of the bleeding point was achieved by radionuclide scanning and the segment of abnormal bowel was successfully resected.