Radiographic demonstration of common bile duct varices

Abstract

Varicose veins may occur along the course of the common bile duct in patients with extrahepatic obstruction of the portal vein. These may cause partial biliary obstruction or excessive bleeding during biliary surgery. The cholangiographic appearance of choledochal varices is described.Key words: Biliary tract, varices -Portal hypertension, angiography. enlargement of the pancreas. ERCP demonstrated an irregular stricture in the body of the pancreas suspicious for malignancy. The pancreatic tail was not filled. The distal CBD was also visualized ( Fig. 1) and showed multiple smooth extrinsic impressions along the CBD which were felt to represent varicose venous collaterals. Celiac and superior mesenteric angiography ( Fig. 2) demonstrated complete occlusion of the splenic and distal portal veins. Extensive collateral veins were visualized in the region of the hepatoduodenal ligament along the course of the CBD. These corresponded to the impressions on the CBD seen at ERCP. The patient was subsequently proven to have carcinoma of the pancreas.Varicose veins of the esophagus, stomach, duodenum, and gallbladder have been well described [1]. Varicosities of the common bile duct are less well known. Following extrahepatic obstruction of the portal vein, hepatopetal collaterals may develop within the hepatoduodenal ligament around the common bile duct. The cholangiographic appearance of these choledochal varices has not been previously described. This case report demonstrates the appearance of common bile duct (CBD) varices visualized at endoscopic retrograde cholangiopancreatography (ERCP). Case ReportA 58-year-old woman was referred for evaluation of weight loss, diarrhea, abdominal distention, and abdominal pain radiating to the back. Four months prior to the present admission she had undergone diagnostic laparotomy which revealed chronic pancreatitis. Multiple pancreatic biopsies at that time revealed no evidence of malignancy. The patient denied a past history of gallbladder disease, jaundice, and ethanol abuse. Physical examination demonstrated ascites. Significant laboratory determinations included alkaline phosphatase 33 U, GGTP 20 IUL, amylase 19 1UL, and total bilirubin 0.5 mg/dl (all within the normal range). The ascitic fluid amylase was normal. Ultrasound documented ascites and splenomegaly. Computed tomography of the abdomen revealed irregular Address reprint requests to :

Portal Cavernoma Cholangiopathy: Consensus Statement of a Working Party of the Indian National Association for Study of the Liver

“…Though surgical hazards posed by common bile duct (CBD) varices were recognized in the late 1970s, 10 it was the seminal paper by Webb and Sherlock 11 that focussed attention on this condition. Choledochal varices were first demonstrated on cholangiography by Williams in 1982, 12 which was later confirmed by other workers. 13,14 That collateral decompression by portosystemic shunt (PSS) surgery can lead to reversal of biliary obstruction was first reported in 1988, 15 an observation corroborated and qualified subsequently.…”

Bile Duct Varices

“…Congenital conditions that cause such obstruc¬ tions are rare. Causes that stem from acquired conditions are grouped into three general categories: (1) inflammatory/ infectious; (2) neoplastic; and (3) obstruction secondary to stasis. The first category includes pancreatitis, pancreatic pseudocyst formation, schistosomiasis, omphalitis (posttraumatic or newborn acquired), and septic thrombo¬ phlebitis in the drainage area of the portal system (pylephlebitis).…”

Analysis of bile in various hepatobiliary disease states: A pilot study

“…[12] Williams et al ., were the first to report cholangiographic changes caused by choledochal varices. [13] Our study clearly shows that the pancreatic enzymes also cause weakness of wall of bile duct and along with biliary obstruction (due to cavernous malformation) increases the severity of portal biliopathy. In patients of Group 3, the patient who had fever had significantly higher levels of calcium in the bile indicating inflammatory pathology in the ongoing process.…”