PICTURES IN DIGESTIVE PATHOLOGY

 

Acute cholangitis and hemobilia in a patient with liver cirrhosis and portal vein cavernomatous transformation

Colangitis aguda asociada a hemobilia en un paciente con cirrosis hepática y cavernomatosis portal

 

 

Helena León-Brito¹, María Fraile-González¹, Irene Aresté-Anduaga¹, Juan Isidro Úriz-Otano¹, David Ruiz-Clavijo-García¹, José Carlos Súbtil-Íñigo², Eduardo Albéniz-Arbizu¹, Javier Eguaras-Ros¹ and Carlos Jiménez-López¹

¹Department of Gastroenterology and Hepatology. Complejo Hospitalario de Navarra B.
²Department of Gastroenterology. Clínica Universidad de Navarra. Pamplona, Navarra. Spain

 

 

Introduction

Portal hypertensive cholangiopathy (PHC) includes bile duct (BD) abnormalities seen in patients with extrahepatic portal vein obstruction (EPVO). The formation of varices in the epi- and paracholedochal venous plexes which compress the biliary tract take part in its pathogenesis (1,2). Its course is usually asymptomatic, being obstructive jaundice and hemobilia rare manifestations of this entity (3,4). The latter is related to choledocholithiasis and BD manipulation, and less frequently to choledochal varices (4).

 

Case report

A 71-year-old male with an alcoholic liver cirrhosis and a previous history of esophageal variceal hemorrhage, portal vein thrombosis recanalization, transcutaneous intrahepathic portosystemic shunt (TIPS) and portal vein cavernomatous transformation was admitted to our hospital with fever, jaundice and abdominal pain which was consistent with an acute cholangitis. The endoscopic retrograde cholangiopancreatography showed an irregular extrahepatic BD with multifocal stricturing and dilation. Several blood clots were removed with persistence of various repletion defects. Differential diagnosis contemplated principally cholangiocarcinoma and sclerosing cholangitis (Fig. 1). The study was completed with computed tomography imaging, in which a non-permeable TIPS and portal hypertension signs were seen. An endoscopic ultrasonography was practiced on discharge. The main findings were esophageal and gastric varices, perisplenic and periportal collateral circulation, superior mesenteric vein cavernomatous transformation and collateral circulation around the BD, with a prominent vascular bundle in the walls of the extrahepatic BD and cystic duct, compatible with choledochal varices (Figs. 2 and 3).

 

 

Discussion

PHC, found in 80-100 % of the patients with EPVO, is only symptomatic in 5-30 % of the cases (2). Its clinical manifestations include abdominal pain, jaundice, acute cholangitis and exceptionally hemobilia and secondary biliary cirrhosis (3). Endoscopic ultrasonography plays an increasingly important role in the diagnosis of PHC (1,2), as it additionally rules out other clinical entities such as choledocholithiasis, cholangiocarcinoma, ampuloma, pancreatic processes and lymphoma (5).

 

References

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2. Chandra R, Kapoor D, Tharakan A, Chaudhary A, Sarin SK. Portal biliopathy. J Gastroenterol Hepatol 2001;16:1086-92.         [ Links ]

3. Condat B, Vilgrain V, Asselah T, O'Toole D, Rufat P, Zappa M, et al. Portal cavernoma-associated cholangiopaty: A clinical and MR cholangiography coupled with MR portography imaging study. Hepatology 2003;37:1302-8.         [ Links ]

4. Green MH, Duell RM, Johnson CD, Jamieson NV. Haemobilia. Br J Surg 2001;88:773-86.         [ Links ]

5. Suárez V, Puerta A, Santos LF, Pérez JM, Varón A, Botero RC. Portal hypertensive biliopathy: A single center experience and literature review. World J Hepatol 2013;5:137-44.         [ Links ]