PORTAL BILIOPATHY^-www.drkeyurbhatt.in*

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

Chaudhary A, Dhar P, Sarin SK, Sachdev A, Agarwal AK, Vij JC, Broor SL.

Gastrointest Endosc. 1999 Nov;50(5):646-52.

Department of Gastrointestinal Surgery, Govind Ballabh Pant Hospital, New Delhi, India.

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.

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Biliary changes in extrahepatic portal venous obstruction: compression by collaterals or ischemic? - - - called as PORTAL HYPERTENSIVE BILIOPATHY^-www.drkeyurbhatt.in*

BY Dhiman RK, Puri P, Chawla Y, Minz M, Bapuraj JR, Gupta S, Nagi B, Suri S.

Department of Hepatology, Postgraduate Institute of Medical Education & Research, Government Medical College, Chandigarh, India.

Gastrointest Endosc. 1999 Nov;50(5):646-52.

Abstract

BACKGROUND:

The postulated mechanisms of biliary abnormalities in extrahepatic portal venous obstruction (EHPVO) are either extrinsic compression by collaterals or ischemic injury due to venous thrombosis. If the former hypothesis is correct, then biliary changes should revert to normal after portasystemic shunt surgery.

METHODS:

Five patients with EHPVO who underwent portasystemic shunt surgery were studied. One of these patients had obstructive jaundice due to portal cavernoma. Endoscopic retrograde cholangiography (ERC) was performed before as well as after the shunt surgery. Doppler ultrasound and splenoportovenography were obtained to confirm the diagnosis of EHPVO as well as shunt patency.

RESULTS:

All patients had biliary abnormalities on pre-shunt ERC. The post-shunt ERC showed partial reversal of biliary abnormalities in 3 patients, complete reversal in 1 patient, and no reversal in 1 patient. Smooth strictures opened after shunt surgery and proximal dilatation disappeared in most patients. The indentations and caliber irregularities disappeared after shunt surgery, whereas angulations and ectasias of biliary ducts persisted.

CONCLUSION:

Shunt surgery results in regression of some of the biliary abnormalities and relieves biliary obstruction, suggesting that mechanical

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  compression by collaterals is the mechanism behind biliary abnormalities in EHPVO. However, some biliary changes persist after shunt surgery signifying fixed obstruction due to ischemia or fibrous scarring. Thus, the two theories are not mutually exclusive.

CASES: Cholecystectomy @ extreme of ages^-www.drkeyurbhatt.in*

CASE 1 : 

92 yrs male with perforated GB & Sepsis..
Surgery: Open Cholecystectomy and drainage
pt was discharged on POD 5.

CASE 2 : 

86 Yrs male with GALL STONES & CBD Stones..
ERCP & Removal of stone  - > lap Cholecystectomy. Discharged on POD 1.

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CASE: EXTREME CASE OF chronic pancreatitis --- LPJ, HJ, GJ^-www.drkeyurbhatt.in*

37 Yrs male with intermitant pain in abdomen for 3 yrs
h/o DM for 2.5 yrs
h/o wt loss of 20 kg in 2.5 yrs
h/o gastric vomiting on and off with wt loss of 10 more kg in last 3 months....

Imaging s/o: chronic pancreatitis with stones and calcifications...
with portal vein thrombosis, lower CBD stricture, duodenal Narrowing & GOO

SURGERY: Roux en Y -  Lateral pancreatico jejunostomy, Hepatico Jejunostomy, Gastro jejunostomy.

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CASE: Colo colic Intucessecption : A minimal invasive approach^-www.drkeyurbhatt.in*

62 yrs female with acute abdomen
OBSTIPATION For last 5 days

On investigation found to have Colo - colic Intucessecption near splenic flexure and large bowel obstruction.

FIRST STAGE:

Hydrostatic reduction of Intucessecption in emergency with oral contrast and saline p/r

SECOND STAGE:

Na Picosulfate oral ingestion for two consequitive days to clear bowel..

Check CT s/o total reduction of Intucessecption with empty bowel. and a small stack with the lead point of intucessptum (a lipoma)

THIRD STAGE:

Colonoscopic  removal of polyp and pt was discharged on Next day.

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