Obstructive Jaundice Caused by Portal Biliopathy Associated with Essential Thrombocytosis: A Case Report

( Woo Hee Cho ),( Kwang Woo Nam ),( Ki Bae Bang ),( Joon Ho Choi ),( Hyun Deok Shin ),( Seok Bae Kim ),( Jung Eun Shin ),( Hong Ja Kim ),( Il Han Song ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Most of obstructive jaundice is caused by pancreatobiliary malignancy or stone. Extrahepatic bile duct obstruction by peribiliary collateral vessels is very rare and association with essential thrombocytosis has not been reported. Portal biliopathy (PB) refers to biliary obstruction that is associated with portal cavernoma. These changes occur as a result of the peribiliary collateral vessels cause extrinsic compression of the intrahepatic and extrahepatic bile ducts. We report a case of patient with obstructive jaundice caused by PB which is associated with essential thrombocytosis. A 66 years old woman, diagnosed with essential thrombocytosis 6 years ago, presented with jaundice for 2 weeks. Laboratory studies showed AST 37 U/L, ALT 44 U/L, Total bilirubin 20.50 mg/ dL with direct fraction 15.60 mg/dL, Alkaline phosphatase 195 IU/ L, gamma-GTP 124 IU/L, PT 12.9 second, INR was 1.14. Hepatitis B and C were non-reactive. Doppler ultrasound and contrast-enhanced CT abdomen noted portal cavernoma and splenomegaly, however, liver was grossly normal. Magnetic resonance cholangiopancreatography showed cavernous transformation of the portal veins and seen to encircle the extrahepatic bile ducts (Fig. 1). Endoscopic retrograde cholangiography with stent insertion was performed for relieving obstructive jaundice. Cholangiogram showed an irregularly narrowed extrahepatic bile duct caused by extrinsic compression of tortuous collateral vascular structures (Fig. 2). An initial nasobiliary drain followed by self-expandable metal stent deployment was done. There was a significant fall in the serum bilirubin level from 20.50 mg/dL to 5.74 mg/dL after 6 weeks. Obstructive jaundice caused by PB is distinctly uncommon. Proper management is important because prolonged biliary obstruction can lead to chonlangitis or secondary biliary cirrhosis.

폐쇄성 황달을 동반한 간세포암 환자에서 담관조영소견의 분석

송일한(Il Han Song),고문수(Moon Soo Koh),최호순(Ho Soon Choi),이성구(Sung Koo Lee),정영화(Young Hwa Chung),김명환(Myung Hwan Kim),이영상(Yung Sang Lee),서동진(Dong Jin Suh),민영일(Young Il Min) 대한소화기학회 1996 대한소화기학회지 Vol.28 No.1

N/A Background/Aims: Jaundice is present in 19-44% of patients with hepatocellular carcinoma(HCC) at the time of diagnosis. The mechanisms of jaundice are associated with cirrhosis, tumor infiltration into the hepatic parenchyma, and bile duct obstruction. Causes of obstructive jaundice secondary to bile duct obstruction in HCC are bile duct invasion of tumor, tumor thrombi, blood clot of hemobilia, and direct bile duct compression of tumor or metastatic lymph n3e. Methods: To evaluate levels and causes of bile duct obstruction in HCC patients with obstructive jaundice and to assess its survival according to causes of obstructive jaundice, we performed retrospective study, from March 1992 to June 1994, with HCC patients with obstnictive jaundice who under- went endoscopic retrograde cholangogiraphy and/or percutaneous transhepatic cholangiography. Results: The commonest level of bile duct obstruction was common hepatic duct(35.3%), followed by common bile duct(23.5%). The causes of obstruction type were tumor invasion(58.8%), tumor thromhi(29.4%), blood clot with hemobilia(5.97o), and bile duct compression hy tumor (5.9%), in order. The level of bile duct obstruction in most cases of tumor invasion was common hepatic duct while in cases of tumor thrombi, common bile duct was the frequent site. There v:as no difference in levels and types of bile duct obstruction according to tumor types of HCC. The su.rvival period of patients with tumor thrombi was significantly longer than that of patients with bile duct invasion(p0.05). Conclusions; HCC involving bile duct will be found frequently with increased use of direct cholangiograpy. The commonest type of bile duct obstruction in HC'C was duct invasion, so aggressive and adequate treatment for HCC may be useful in management of bile duct obstruction. (Korean J Gastroenterol 1996;28: 101 - 110)

Obstructive Jaundice Caused by Clonorchiasis-associated Duodenal Papillitis: A Case Report

임준욱,주광로,신현필,차재명,이정일,임성직 대한의학회 2011 Journal of Korean medical science Vol.26 No.1

We describe an unusual presentation of Clonorchis sinensis infection with obstructive jaundice due to duodenal papillitis which was relieved dramatically by endoscopic sphincterotomy. A 26-yr-old male presented with complaints of fatigue, weight loss and painless jaundice. The history was significant for frequent ingestion of raw freshwater fish. The patient underwent endoscopic retrograde cholangiopancreatography for evaluation of obstructive jaundice. The duodenal papilla was markedly edematous with a bulging configuration and hyperemic changes at the orifice. Cholangiography revealed mild bile duct dilatation and irregular wall changes with multiple indentations. However, there were no biliary stricture or stones noted as the cause of obstructive jaundice. We performed an endoscopic sphincterotomy for effective bile drainage through the duodenal papilla. After the sphincterotomy, the patient’s jaundice was dramatically improved. Pathology of the duodenal papilla showed eosinophilic infiltration of the mucosa. Parasitic eggs, consistent with the diagnosis of C. sinensis, were found in the bile sample.

담관내 간세포암에 의한 폐쇄성 황달 1례

이구,서정일,조진용,양창헌,이영실,박동건,구정태,이창우 동국대학교 의학연구소 1999 東國醫學 Vol.6 No.-

일반적으로 간세포암에 있어서 황달은 광범위한 종양의 침윤이나, 기존의 간경변에 기인된 경우가 흔하다. 초기부터 폐쇄성 황달을 보이는 경우는 매우 드물며 종양에 의한 담관 침윤의 기전으로는 종양조직의 담관내 성장, 괴사된 종양조직의 하방이동 그리고 담도출혈(hemobilia) 등이다. 저자들은 폐쇄성 황달을 동반한 간세포암을 경험하였는데 환자는 진행성 황달과 우상복부 동통을 주소로 내원하여 시행한 복부 초음파와 전산화단층촬영상 경도의 담관확장 소견 이외 종괴는 관찰되지 않았다. 역행성 췌담관조영술(ERCP) 상 근위 총수 담관에 둥근 음영 결손을 보였으며 내시경적 결석제거술을 시도하였으나 실패하였다 수술소견상에서 간 표면에는 종괴는 보이지 않았으며 총수담관 내 구형의 연조직이 발견되었고 병리조직상 고분화형의 간세포암의 소견을 보였다. 수술 후 시행한 간동맥조영술과 lipiodol 전산화단층촬영에서 간의 미엽에 원발 병소를 발견 할 수 있었다. 고식적인 복부 초음파검사나 전산화단층촬영의 진단적인 한계 때문에 간세포암의 기계적인 폐색에 의한 폐쇄성 황달이 의심되는 경우, 특히 기저의 간경변이나 B형 간염 바이러스 보균 상태일 경우나 역행성 췌담관 조영술상 육안적으로 담석을 증명하지 못할 경우 수술 전 원인적 진단을 위한 보다 적극적인 검사가 필요할 것으로 사료된다. Jaundice in association with an ordinary hepatocellular carcinoma results from extensive hepatic infiltration with tumor and/or underlying cirrhosis. It is rare, however, for obstructive jaundice to occur initially. The mechanism is related to the invasion of intrahepatic bile ducts by the carcinoma and the consequent mechanical obstruction is due to either a distally continuous growing tumor into the biliary tree, detachment of necrotic tumor fragment, or hemobilia. We experienced a case of hepatocellular carcinoma associated with obstructive jaundice. The patient was 51-rear-old female and visited our hospital with progressive jaundice and right upper abdominal Pain. Abdominal ultrasonography and conventional C.T. showed mild dilatation of biliary duct, but there was no evidence of hepatic parenchymal mass lesion. E.R.C.P. was performed and showed smooth filling defect in proximal common bile duct but endoscopy-guided extraction failed. At operation, no tumor was grossly found on the surface of the liver and the common bile duct was explored and round soft tissue was evacuated. These material was a pathologically well-differentiated hepatocellular carcinoma After operation, hepatic angiography with lipiodol-CT were Performed and primary parenchymal leson could be detected in caudate lobe of liver. Because conventional ultrasonography and CT have diagnostic limitation, more aggressive diagnostic approtch should be performed before surgery when obstructive jaundice is suspected as a mechanical complication of hepatic carcinoma, especially with underlying cirrhosis or hepatitis B carrier and failure of documentation of gross biliary stone during ERCP.

위암의 간문맥 전이로 발생한 악성 폐쇄성 황달에 대한 외부 방사선치료 효과

양광모(Kwang Mo Yang),김준희(Joon Hee Kim),김철수(Chul Soo Kim),시현숙(Hyun Suk Suh),김예희(Re Hwe Kim) 대한방사선종양학회 1995 Radiation Oncology Journal Vol.13 No.4

목적 : 위암의 간문맥 임파절 재발로 발생한 악성 폐쇄성 황달치료에 있어서 외부 방사선치료의 효과를 평가해 보고 치료의 결과에 영향을 미칠 수 있는 요인을 알아보고자 하였다. 방법 : 1984년부터 1993년까지 위암의 간문맥 전이로 악성 폐쇄성 황달이 발생한 32명중 3000cGy이상의 방사선량이 조사된 23명을 대상으로 하였다. 치료 결과에 영향을 미칠 수 있는 요인을 알아보기 위하여 방사선량, 황달발생 당시의 질병의 진전정도 및 황달을 일으키는 종괴의 위치, 방사선치료 전 총 bilirubin치, 다른 치료와의 병합여부, 원발병소의 수술정도, 재발전 병기를 분석하였다. 외부 방사선치료는 4백만 전자볼트 선형가속기를 이용하여 주 5회, 1회 180-300cGy를 간문맥을 포함하는 부위에 3000cGy-5480cGy(중앙값 3770cGy, TDF 49-86 3420cGy-5580cGy 중앙값 TDF 65, 4140cGy/23fx)가 조사되었다. TDF 65(4140cGy/23fx) 이상과 미만을 받은 환자는 각각 13, 10명이었다. 결과 : 전체 환자 32명중 완전관해 13명, 부분관해 5명, 무반응 5명이었다. 전체 환자의 종양 생존 기간은 5개월이나 완전관해의 경우는 11개월이고 부분관해와 무반응의 경우 각각 3개월이었다. 완전관해를 보인 13명중 6명이 1년 이상 생존하였다. 완전관해의 경우와 부분관해, 무반응과의 생존 기간의 비교에서 의미있는 차이를 보였다(p Purpose : Since 1983, authors have conducted a study to evaluate the effect of external radiation therapy and to determine affected factors in management of the patients with malignant obstructive jaundice due to porta hepatis metastasis from stomach cancer. Materials and Methods : Thirty two patients with malignant obstructive jaundice due to porta hepatis metastasis from gastric cancer were presented. We have analysed 23 patients who were treated with external radiation therapy of more than 3000cGy. The radiation dose, disease extent at development of jaundice, total bilirubin levels before radiation therapy. initial stage of gastric cancer were analyzed to determine affected factors in radiation therapy. External radiation therapy was delivered with a daily dose of 180-300cGy. 5 times a week fractionation using 4 MeV linear accelerator. The radiation field included the porta hepatis with tumor mass received more than 3000cGy. total irradiation dose was ranged from 3000cGy to 5480cGy. median 3770cGy. Among 23 patients, 13 patients were delivered more than equivalent dose of TDF 65(4140cGy/23fx). Results : Among 23 patients, complete, partial and no response were observed in 13, 5, 5 patients, respectively. The median survival for all patients was 5 months. The significant prolongation of median survival was observed in complete responder(11 months) as compared to partial and no responders(5 months, 5 months, respectively). Out of 13 patients with complete response, 6 patients lived more than a year. Among 13 patients receiving more than 4140cGy equivalent dose, complete, partial and no response were observed in 10.2 and 1 patients, respectively. The median survival for all these patients was 9.5 months. The median survival for complete responders(10/13) was 11.5 months. Among 10 patients receiving less than 4140cGy equivalent dose, complete, partial and no response were observed in 3, 3, 4 patients. respectively. The median survival for all these patients was 4.3 months. therefore, the radiation dose affected the results of treatment. For the complete response with prolongation of survival duration, at least 4140cGy equivalant dose should be delivered to porta hepatis. In valuation of the disease extent, 7 patients of 13 complete responders showed localized disease in porta hepatis or peripancreatic area, but all patients with partial and no response showed wide extensive disease or persistant disease of primary gastric cancer. Therefore, the patients with the localized disease were the higher probability of complete response and long term survival. This study suggested that the radiation dose and the disease extent at development of jaundice affected in radiation therapy for malignant obstructive jaundice. There were no serious complications related to external radiation therapy. Conclusion : External radiation therapy only could achieve the palliative effect in the patients with malignant obstrctive jaundice due to porta hepatis metastasis from stomach cancer. This study suggested that the prolongation of survival duration could be acheived in complete responders and radiation dose. extent of disease affected the results of treatment of malignant obstructive jaundice

Comparison of Infection between Internal-External and External Percutaneous Transhepatic Biliary Drainage in Treating Patients with Malignant Obstructive Jaundice

Xu, Chuan,Huang, Xin-En,Wang, Shu-Xiang,Lv, Peng-Hua,Sun, Ling,Wang, Fu-An Asian Pacific Journal of Cancer Prevention 2015 Asian Pacific journal of cancer prevention Vol.16 No.6

Purpose: Percutaneous transhepatic biliary drainage (PTBD) is a form of palliative care for patients with malignant obstructive jaundice. We here compared the infection incidence between internal-external and external drainage for patients with malignant obstructive jaundice. Methods: Patients with malignant obstructive jaundice without infection before surgery receiving internal-external or external drainage from January 2008 to July 2014 were recruited. According to percutaneous transhepatic cholangiography (PTC), if the guide wire could pass through the occlusion and enter the duodenum, we recommended internal-external drainage, and external drainage biliary drainage was set up if the occlusion was not crossed. All patients with infection after procedure received a cultivation of blood and a bile bacteriological test. Results: Among 110 patients with malignant obstructive jaundice, 22 (52.4%) were diagnosed with infection after the procedure in the internal-external drainage group, whereas 19 (27.9%) patients were so affected in the external drainage group, the difference being significant (p<0.05). In 8 patients (36.3%) in the internal-external group infection was controlled, as compared to 12 (63.1%) in the external group (p< 0.05). The mortality rate for patients with infection not controlled in internal-external group in one month was 42.8%, while this rate in external group was 28.6% (p< 0.05). Conclusion: External drainage is a good choice, which could significantly reduce the chance of biliary infection caused by bacteria, and decrease the mortality rate at one month and improve the long-term prognosis.

변이 우간동맥에 의한 총담관 압박으로 발생한 폐쇄황달

김민재 ( Min Jae Kim ),최영 ( Young Choi ),윤건중 ( Gun Jung Youn ),이래석 ( Rae Seok Lee ),박종호 ( Jong Ho Park ),이주용 ( Jue Young Lee ),주연호 ( Yeon Ho Joo ),이윤복 ( Yun Bok Lee ) 대한췌장담도학회 2014 대한췌담도학회지 Vol.19 No.2

Extrahepatic bile duct can be compressed by right hepatic artery (RHA) and cause a variety of hepatobiliary symptoms. This condition is referred to as RHA syndrome. A 20-year-old man was admitted because of jaundice. No stones or tumor were visible on CT scan and endoscopic retrograde cholangiopancreatography. However, RHA was seen traversing and compressing the mid common bile duct (CBD) with resultant upstream dilatation. The patient was diagnosed with obstructive jaundice due to compression of the CBD by variant RHA originating from gastroduodenal artery. After separation and mobilization of the variant RHA, obstructive jaundice was resolved. Herein, we report a case of a variant form of RHA syndrome that was successfully managed by surgery.

간외담관의 폐쇄소견을 보인 원발성 간세포암 - 담관조영술 소견을 중심으로 -

박승우(Seung Woo Park),송시영(Si Young Song),정재복(Jae Bock Chung),강진경(Jin Kyung Kang),박인서(In Suh Park),이우정(Woo Jung Lee),김병로(Byong Ro Kim) 대한소화기학회 1995 대한소화기학회지 Vol.27 No.1

N/A Rackground/Aims: Mechanisms of hepatomo-in(luced biliary obstruction include pedunculated tumor extension, obturating bemorrhagic clot and tumor debris, direct invasion of the biliary system by a tumor nodule, and metastatic lymph node compression of the major ducts in the porta hepatis. Usually, the diagnosis has been an unexpected finding at surgery or postmortem and preoperative diagnosis is seldom made, it is very meaning to find out thc characteristics to predict the hepatoma-induced biliary obstruction. This study I, conducted to elucidnte the findings in patients with hepatoma-induced obstructive jaundice. Methods: We reviewed clinical, radiological and surgical findings in six cases of hepatocellular carcinoma who showed jaundice due to obstruction of the extrahepatic bile duct and confirmed histologically from 1990 to 1993, and analyznl the cholangiographic fingdings. Results: The mean age of the patients was 54.2 years and 4 were males, 2 females. The common cholan-giographic tmdings of a11 case. Wvre bulky intraluminal tilling defects, which expand the biliary trce by tumor itself. Thesc defects somewhat resemble a wine- g1ass appearance. The margins of defects were slightly lobulated and somewhat irregular. Defects occurred at various level from the intrahepatic raclicle to the <lista1 common hile duct, however most frequently located in the common hepotic duct. Total obstruction was demonstrated in 2 cases, however stenosis wa.I not noticed in all of our ca.ies. Tissue diagnosis was madc preoperatively by cytologic examination of hile ohtained during ERCP in 2 cases and remaining 4 cases diagnosed by operatively. Conclusions: We may suspect this disease on the findings of bulky filling defects expanding the extrahepatic bile duct especially in common hepatic duct level resembling wine-gIass, and which has lobulated and somewhat irregular surface on cholangiogram. Additionally even though the preoperative histologic diagnosis is difficult, patho1ogic examination of the extracted materials or bile, transpapillary biopsy during ERCP or peroral choledochoscopic examinations are mandatory for the confirmative diagnosis. (Korean J Gastroenterol 1994; 27: 83-95)

폐쇄성 황달 환자에 있어서 자기공명 담도 촬영술의 유용성

이선영(Sun Young Yi),백승연(Seung Yon Back) 대한소화기학회 1996 대한소화기학회지 Vol.28 No.5

N/A Backgound/Aims: The effectiveness of magnetic resonance cholangiography(MRC) for diagnosing obstructive jaundice, as a noninvasive alternative to direct cholangiography(endoscopic retrograde cholangiopancreatpgraphy; ERCP or percutaneous transhepatic cholangiography;PTC) is studied. The goal of the study is to evaluated the level of reliability and efficacy of MRC for identifying the obstruciton site and the cause of it. Methods: Thirty two consecutive patients with obstructive jaundice are included in the study. Non-breath-hold, heavily T2-weighted, fast spin echo MRC is used to obtain; 2D-axial, coronal, and 3D-images with maximal intensity projection protocol. We evaluated all patients retrospectively by ERCP, PTC, or operation to compare the results. Results: The causes of obstruction are 13 common bile duct cancer cases, 2 pancreatic cancer cases, 8 extrahepatic duct stone cases, 3 intrahepatic duct stone cases, and 3 intra and extrahepatic duct stone cases. The level of obstruction is correctly diagnosed with MRC for 100% of common bile duct cancer and pancreatic cancer cases, 90.9% of extrahepatic duct stone cases, and 66.7% of intrahepatic duct stone cases. MRC revealed the correct causes of obstrcution for 80% of common bile duct cancer and pancreatic cancer, 81.8% of extrahepatic duct stone, and 50% of intrahepatic duct stone. Conclusions: MRC provided a accurate level of obstruction and diagnosis for common bile duct cancer, pancreatic cancer, and extrahepatic duct stone but not for intrahepatic bile duct stone. Therefore, MRC may be used with caution as a noninvasive altemative to invasive cholangiography, if not as a cornplete replacement of it. (Korean J Gastroenterol 1996; 2S:690 - 696)

간세포암 환자에서 간동맥혈관색전술 후 종양혈전에 의해 발생한 총담관 폐쇄증 1예

최훈,김석배,신기철,신현덕,윤세영,신정은,김홍자,송일한 대한소화기내시경학회 2009 Clinical Endoscopy Vol.38 No.5

The jaundice in hepatocellular carcinoma patient can be found when the tumor progresses or hepatic function deteriorates. Rarely, it can be occurred when the bile duct is obstructed. The main reason of obstructive jaundice in hepatocellular carcinoma is bile duct invasion of tumor, tumor thrombus, blood clot of hemobilia and direct bile compression by tumor or metastatic lymph node. Although the tumor thrombi among them is difficult to think, prompt diagnosis and treatment should be done because the symptom and prognosis can be improved by removal of the tumor thrombus. We experienced a case of hepatocellular carcinoma patient associated with obstructive jaundice caused by tumor thrombus after transarterial chemoembolization (TACE). The tumor thrombus was removed by endoscopic retrograde cholangiopancreatography (ERCP) and confirmed as degenerated hepatocellular carcinoma cell. 간세포암 환자에서 황달은 대부분 기저 간경변이 악화되거나 암조직이 간 전반에 걸쳐 광범위하게 침윤될 때 볼 수 있다. 이 외에 드물게는 담도 폐쇄에 의해서도 황달이 나타날 수 있는데 폐쇄성 황달이 발생하는 기전으로는 종괴에 의한 담도 침윤, 종양혈전에 의한 담도 폐쇄, 혈액담즙증에 동반된 혈괴에 의한 담도 폐쇄, 종괴에 의한 담도 압박, 림프절 종대에 의한 담도 압박 등이 알려져 있다. 이중에서도 종양혈전에 의한 폐쇄성 황달은 빈도가 드물어 의심하기 힘들지만 종양혈전을 제거함으로서 환자의 증상 및 생존기간이 향상될 수 있기 때문에 빠른 진단과 치료가 필요하다. 저자들은 간동맥화학색전술 후 총담관의 종양혈전으로 인해 폐쇄성 황달이 발생한 간세포암 환자를 내시경적 역행성 담췌관조영술로 치료하여 문헌고찰과 함께 보고한다.