Successful Trial of Octreotide and Ketorolac for the Management of Increased Biliary Drain Output: A Case Report

Abstract

We describe a 69-year-old male patient with the status of obstructive jaundice post percutaneous biliary drainage for prior obstructive jaundice and who presented with a complaint of generalized weakness and increased output from the drainage tube. The patient developed worsening jaundice, which was noted to be obstructive in nature with a marked dilatation of the biliary tree and a distal obstruction of the common bile duct. Subsequently, a percutaneous biliary drain was placed for symptomatic management. However, the patient continued to have increased output from the drain, approximating 3-4 liters a day, which made the patient dependent on continuous intravenous hydration. The case presented a therapeutic challenge in reducing the drainage amount. We have tried a successful approach based on the physiologic effect of octreotide and nonsteroidal anti-inflammatory drugs (NSAIDs) in the formation of bile secretion. This approach has not been clearly described in the literature. We highlight the importance of further study to validate the use of these medications in similar clinical scenarios.

Acute kidney injury due to high-output external biliary drainage in a patient with malignant obstructive jaundice: a case report

“…Of them, only three exceeded outputs of more than 2 liters, as in our patient, and needed aggressive fluid therapy [5]. Similar to our case, another report also described a high output from an EBD of 3–4 liters a day complicated by pre-renal AKI which was effectively treated with octreotide and nonsteroidal anti-inflammatory drugs (NSAIDs) [6]. It is unclear from these reports or available evidence what the mechanism or risk factors for a high-output biliary drain are.…”

“…However, aggressive fluid therapy, renal support with hemodialysis, octreotide, and NSAIDS were suggested to be effective in the management. The basolateral membrane of cholangiocytes contains secretin receptors which cause a cyclic adenosine monophosphate (cAMP)-dependent increase in bile release [6]. Thus, the use of octreotide was justified based on its ability to inhibit secretin-mediated bile release.…”

High-volume post-obstructive choleresis (biliary hyperproduction) with acute kidney injury after choledochotomy, gallstones extraction, and T-tube drainage, successfully treated with octreotide

“…Several papers underline overlooked bile cast nephropathy as a potential cause of renal injury in patients with hyperbilirubinemia, which we excluded in our patient. 4,5 Literature on managing the persistent choleresis from the biliary drain is scarce, although octreotide is reportedly helpful (2). PubMed search for "highvolume biliary excretion" or "percutaneous biliary drainage" combined with "octreotide" or "acute kidney injury" retrieves 21 results, where only three of them are related to our case.…”

“…Although we found a report on the beneficial effect of ketorolac, we decided to avoid nonsteroidal anti-inflammatory drugs (NSAID) to avoid potential nephrotoxicity. 1,2 The patient's laparotomy wound healed well, and we removed the stitches. On the ninth postoperative day, we performed secondary cholangiography through a Ttube, demonstrating the passage of bile into the duodenum without signs of residual stones or contrast leakage (Figure 3).…”

High Output External Biliary Drainage Leading to Acute Kidney Injury in a Patient with Malignant Obstructive Jaundice: A Rare Case Report

“…One of the earliest pieces of literature published byTaber et al in 1982 in the review of 120 cases showed 7 of the patients' daily biliary output exceeded average amount and only three exceeded outputs of more than 2 liters, as in our case demanding fluid resuscitation.2 In another case report published by Jayarajah et al mentioned development of high biliary output AKI in case of blocked SEMS and failure of internal catheterization requiring hemodialysis 6. Literature regarding percutaneous biliary procedure Nepal is limited, a study by Thapa A et al showed promising result in its role in palliation highlighting the need of further large scale study 4,7,8,9. …”